Sunday, April 02, 2006

We all have to start somewhere!

First Steps by andi2 at currently have the pleasure of my junior registrar being on leave. This is especially so because she has been replaced by an even more junior registrar. In fact, this registrar is so junior that he doesn't know what being a registrar actually means.

Thankfully for him, I do remember what it was like being a registrar for the first time. It is, in fact, just like every other transition that we make in our personal lives and professional careers... learning to trust your own judgement, realising that other people are not always smarter or more knowledgable than you, and accepting that the greater responsibility that comes with being senior means that you have to always keep in mind the "bigger picture". That means that the patient is not your only responsibility.

Perhaps the biggest lesson of all is that there are times when, if you don't do it, nobody will.

While these may seem like very generic observations, they are nonetheless true. As you progress in seniority, they become more and more evident. Unfortunately, there are many health professions where these tenets do not apply.

NHS Blog Doctor's favourite topic at the moment is Nurse Practitioners. I must admit that I think there are some very good Nurse Practitioners out there. They are the ones who know their limitations, and stick to the very straight and narrow area that they are trained in. Unfortunately there are also many who do not, and think that with their protocols and limited clinical skills they can deal with situations that many doctors take years to start to understand.

As a neurosurgical registrar, I had to learn to confidently assess and clear cervical spines. Nobody was going to do this for me. If I made a mistake I had to wear the blame. Perhaps I left a few collars on for longer than necessary, and ordered a few more flexion-extension views than necessary, but that's what it took until I became comfortable with my clinical acumen and responsibilities.

As a vascular surgery covering registrar, I learnt to keep track of my consultants. They changed their on-call rotations regularly, and I could not trust switchboard to keep track correctly. If a AAA came in I had to know who to call, and where they would be. There was little luxury in delay while I tried five different phone numbers.

As a trauma surgery registrar, I had to learn to deal with team conflict. Consultants did not get along, ward rounds were dysfunctional. Politics were rife. Nevertheless, I did my best to smooth things over and ensure that the unit functioned and served its patients well. Was this part of my job description? No, but who else was there to turn to?

As a general surgery registrar, I learnt to deal with private rooms, secretaries, nagging patients from the waiting list, pre-admission stuff-ups, and a barely competent intern going through a divorce. This wasn't part of my medical school training, but one has to accept that as the interface between almost all parts of the hospital and the community, the registrar becomes the non-stop troubleshooting machine.

There have been many other clinical and non-clinical lessons that I have learnt along the way, and it has taken many years to develop my skills and better judgement. Each rotation through an unrelated field, different hospital, different state and different country has only served to teach me how everything can change around me, and yet I am still expected to (and more importantly, able to) oversee every aspect of my patients' care. I can happily say that I can see how "the system" works (or doesn't work) and appreciate the point of view of most other parties in "the system". That doesn't mean that I agree with them, but I think it makes me a better doctor.

I happily admit that my job does not start at 9am and finish at 5pm. That is the nature of being a doctor - or even worse, a surgeon. My responsibilities stay with me when I go home, they carry on for years. Long after I retire I will still be responsible for everything I have done for my patients. If I did not want this responsibility I would never have progressed beyond being a hospital resident. Hmmm... now that is an interesting idea. Perhaps there is a hidden social agenda - given the current need for hospital resident doctors, by scaring them away from becoming registrars and consultants we can increase the RMO workforce? Another topic for another day, I fear.

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