Transcript Being a Medical SPR

Being a Medical Registrar
My thoughts so far
Emma Bailey
SPR Geriatric Medicine
Disclaimer
• I’m a new SPR/ST3
• It’s my opinion only 
“I would like to do (geriatrics, gastro, resp…) but there’s no
way I could/would ever be the medical SPR…”
……………………………….DISCUSS
How I ended up here
• Graduated 2008
• FY1
• Resp, Geriatrics, Surg
• FY2
MRCP Part 1
• Gastro, ITU, Oncology
• CMT1
• Geriatrics, Neurology,
Community/Rehab
MRCP Part 2
• CMT2
• Resp, Cardio, Haem
MRCP Paces
What I am expecting
• Registrar training – 5 years minimum – CCT 2017
• Moving around hospitals for 5 years inc on-calls/nights
• Specialty Certificate Exam at ST5/6
• Eportfolio…groan (but is always improving)…revalidation…
• Maybe….
• +/- 1 year OOP - ?acute ?stroke ?abroad (more and more
opportunities for these coming up)
• +/- time out for further education (?post grad certificate/masters in
ethics/law/palliative care etc)
• +/- time out for family (and then ?less than full time – a lot of
geriatric trainees manage this very successfully)
• All adds time on to CCT!
What I was worried about
• Medical
• Being the (sole) decision maker
• Procedures – especially out of hours
• Not knowing enough/looking stupid
• Missing something
• Being in an emergency situation and not knowing what to do
• Management
• Delegating/organising the team
• Politics
• Workload/Stress
• Being so busy
• Nights/weekends/long days
The reality…
• Medical
• Being the (sole) decision maker
• It comes naturally towards the end of CMT
• You begin to become “an expert” in something
• Being the decision maker actually makes things easier
• You don’t have to trawl the wards doing the “****” – the mundane
tasks are now someone else’s priority
• Less annoying bleeps (still a lot!)
• Your opinion counts
The reality…
• Medical
• Procedures – especially out of hours
• LPs
• Paracentesis
• Chest drain for pneumothorax (often effusions can wait)
• Lots of opportunity to learn, especially if you do specific jobs
• Central lines - continue to be an issue but doesn’t really affect me
that much
• It feels good to be the only one around that
can do something sometimes!!
What I was worried about
• Medical
• Not knowing enough/looking stupid
• You are constantly learning
• You will be surprised how much you DO know just from experience
alone by the time you are an SPR
• Try not to panic and be resourceful! (internet, BNF, guidelines..)
• You CAN call the consultant
• For help or back-up
• They have 10-30 years more experience then you
• In the day – almost ALWAYS consultant presence
What I was worried about
• Medical
• Missing something
•
•
•
•
That’s why there is a team
Same presentations over and over again
Instinct is really important – go with your gut
If you miss something once, you don’t do it again!
• You can’t fix everything in one night shift – be patient
• Be thorough, then decide what can wait and what will make a
difference/change management
What I was worried about
• Medical
• Being in an emergency situation and not
knowing what to do
• You will have seen most of it
• Usually too many people doing too many separate
things
• Take control (that’s what everyone wants)
• It is easier, in my opinion, to DO something
than to NOT DO something
• Leading arrests – either it works or it doesn’t
• The arrest is the last bit in a long chain of events
An Example – when enough is enough
• Setting - Night shift, busy-ish, good SHO and FY1
(&H@N)
• EMRT call to ward
• 76 yr old •man
with breathing
sats of 70%stopped
“End Stage COPD” “NIV
…Then
ceiling” but had been
reasonably stable on ward
• Ahhhh!!!
• –****!
• ABG awful
CO2 11
• By this time NIV was on. (I knew this was a losing
• Gave
asap
• Then starts
fittingFlumazenil
(PMH
epilepsy
too)
battle
really)
• By the time
I get there
areagain
about to give 5mg IV
• Started
• breathing
Callteam
family
asap
Diazepam
Gave Phenytoin
(desperate!)
• STOP! Gave 0.5mg•Diazepam
IV (worried
about
• Still fitting 1 hour later – horrible to watch
respiratory
depression)
• Then
started
fitting… twitching etc
• Fitting stopped…. • Clearly deteriorating
• Dw family – decision to give more
benzodiazepines to stop fitting and to remove NIV
• Patient passes away shortly afterwards
What I don’t like about it
• Rigid following of protocols/pathways with no common sense
• Feeling out of my depth
• Not being able to do a really good job due to workload
• Discharges/returns (or DVTs!)
• Confronting people/disagreeing with people (sort of!)
• Irritated by laziness/rubbish clerkings/inefficiency – taking the flack
• Hard work – not eating/weeing regularly!
• (Nights/weekends)
• Sometimes it feels like everything is your problem!
What I really really enjoy
• Being the “one who can sort things out”
• Being an advocate for a patient
• Finding the details that can make a big difference
• Teamwork – getting to know people and having a laugh
• Leadership/being looked up to
•
•
•
•
Having your opinion count
Looking after the sickest patients – actually “saving lives”
Huge diversity
Less of the rubbish jobs! – can actually be easier
• My quality of life is better as an SPR
• I don’t spend my time doing boring jobs, generally
• More variety – clinics, intermediate care, teaching, meeting families
Why Geriatrics (for me)
• I like older people
• I’m nosey
• Diversity – can never assume anything and people surprise you all
the time
• Delicate balance between a complex medical background and
unique social set ups
• Being good at medicine and basic principles
• Being sensible when looking after a frail older patient
• Being able to admit you haven’t got a clue (but it’ll probably settle)
Why Geriatrics (for me)
• MDT/team – working with funny and generally non-pretentious
people – no one is trying to be a hero
• Working for people with a subtle brilliance
• Challenging stigma and being an advocate for your patient, and
winning small battles
• End of life care – getting it right
• Difficult communication – end of life and NUTRITION– being able to
have the conversations that others hate having
• Delirium – when someone really goes for it!
Why Geriatrics (for me)
• The future is geriatrics and the academic and political world are
starting to realise this
• Opportunities in research, teaching, travelling etc are growing year
on year
• Opportunities to see a problem and fix it both on a small scale and
larger scale are there in abundance
• Flexible training is do-able
• The money is good, locums pay well, job security and can work
anywhere
My advice
• Don’t be put off just because of being the medical SPR – it REALLY
isn’t that bad and a very LOW percentage of your time at work
• All you need for Geri’s is enthusiasm and to be a good doctor, but you
do have to love it to be good at it
• As you progress, it all gets easier
• If in doubt do CMT whilst making your decisions – it will do no harm and
will only help you in whatever specialty you end up doing
• Shadow me/carry my bleep for the day with supervision and see what
you think
• Email me if any questions
• [email protected]
My advice
•Don’t be put off by being
the medical SPR
•Don’t be put off by being
the medical SPR
•Don’t be put off by being
the medical SPR
Thank you
• Any questions?