7 Lessons Learnt From A New Registrar
1. “I am not alone”
Although it may be the middle of the night, in a district general hospital and you are the most senior paediatrician on site, you are never truly alone, no matter how much you convince yourself that you are. If you ask for help, you will get it. Consultants understand and are there to support you. Pride doesn’t even come into it when a child’s health is at stake. They may seem grumpy on arrival after being woken from sleep but they would rather you call than not. Also, anaesthetics and senior A+E doctors are invaluable and can provide a calm additional support when you have an unwell patient.
2. “There are emergencies and there are emergencies”
I had always had a bit of a tendency towards catastrophe. Over the last year I have come to realise that what I had previously considered urgent is not always so. I fretted and fretted about not being able to cannulate the
small baby with a temperature in the middle of the night in order that they could continue to have their antibiotics. I have come to realise that if the child is stable, there is always time to take breath prior to trying again or seek help or advice. If a child is crashing, intra-osseous access is perfectly acceptable and necessary. Also if there are 10 well patients sat on the ward waiting to be sent home but you are stuck with a very sick baby elsewhere, no matter how upset or angry, nursing staff or parents may feel about waiting, it is not your priority at that moment in time and you are completely justified in that.
3. "Choose your battles”
Nursing staff are valuable colleagues with a wealth of experience and may often have their own opinions and suggestions regarding patient care. Their priorities often have a particular focus on reducing patient distress or pain, the wellbeing of parents and occasionally the demands on other nursing staff on the ward. It is important to consider their suggestions and opinions appropriately. As a consultant once told me “There are many ways to skin a cat” and minor differences in treatment are unlikely to significantly affect patient outcome. However in cases where patients are unwell and your treatment plan is being questioned, it is important to explain the rationale behind your plan and seek consultant support if you feel your actions would be the best thing for the patient. I have found this most evident this year when promoting the use of early CPAP in bronchiolitis to prevent further deterioration. This is a fairly new treatment in my hospital and there have been several anxieties amongst nursing staff with regards to its use. However despite this, we have managed to successfully treat several babies with CPAP since the start of the bronchiolitis season this year.
4. “ Don’t ignore your instincts”
I was asked to review a patient on my evening on-call in order to send them home. It was a young boy felt to have a viral illness whose observations had now normalised and was felt to be ready for discharge. However on reviewing him, despite normal observations and only a maculopapular rash on examination, he seemed quiet and ‘not quite right’. We made the decision to keep him in for observation and took some bloods and left a cannula in place. I came in the next day to find out that the boy had come down with meningococcal sepsis overnight but responded well to antibiotics. I was acutely aware of how different the situation could have been if we had sent him home.
5. “Trust your juniors
As a junior I was very much a control freak. I maintained perfectly accurate patient lists, took all new referrals and ticked off my jobs list meticulously throughout the day. As a register, I do not receive the referrals and often need to rely on the SHO’s to do the above when I am busy. Also minor queries and problems from nursing staff/patients do not always reach me as they are dealt with by competent junior staff. I initially found this very difficult and felt as if I had lost the level of control that I had as an SHO. As I have learnt to trust my juniors, this has become easier as I accept that if there is a significant problem they will inform me. It is impossible to do everything yourself and delegation is important. However it is important to have a good oversight of the ward and an understanding of the capability of the individual SHO’s that you are working with in order to judge the level of additional input required from yourself.
6. “Sometimes things need to be said even if they upset people”
No matter how gently you may think that you have given advice, sometimes you upset people but that doesn’t mean that you have done the wrong thing. As a registrar, you are often called upon to say the difficult thing that nobody else wants to say. I saw a 16 year old boy with epilepsy overnight who was having frequent seizures as he was non-compliant with his medication. Dad believed that he was old enough to manage his own epilepsy and had been allowing him to manage his own appointments which he was not attending. During the consultation, I suggested to Dad that his son wasn’t managing his epilepsy well and perhaps he did need a little more support. At the time I felt that I had said this in an appropriate manner but later discovered Dad had been quite upset. I reflected on how I could have said this better and discussed this with colleagues but still felt it was necessary for it to be said and would inevitably have touched a raw nerve with Dad anyway
7. “ We’re all in the same boat”
Having started my first register post in the community, I had limited contact with my register colleagues except for during handover. I felt very much that I was struggling with the pressures of becoming a new registrar more so than other people. However on speaking to a colleague one day about it, I realised that she was also going through a similar experience. From now on, I have made a pact to talk to friends and colleagues when ever I have a bad shift to help me maintain perspective that this is often a difficult and challenging experience for everybody and we can all support each other