How to be a Successful Surgical Registrar
The life of a surgical registrar can be challenging, but the key is to understand the role, commit to the process and make the most of your time whilst training. In considering the question of what makes a good registrar, you first need to understand what it is you’re trying to achieve. Ultimately, you need to be able to practice independently while maintaining collegiality, execute on surgical techniques and make decisions that all ultimately benefit your patients. At the end of your training, your competency will be defined by the skills and experience that you have acquired, not by completion of the formulised training hurdles. At the time when you are faced with a challenging situation, as an independent surgeon, you want to be able to provide your patients with the best decision making and skill execution. And in order to do this, you have to be willing to be trained.
A colleague of mine wrote a document titled ‘Orthopaedic Registrars: The Rules’. This simple guideline contains some well tested truths that were passed on to them in addition to their own perspective. I was given this document early in my registrar career and it served to provide robust advice on how to conduct yourself as a registrar. It contained the classics such as; ‘never be lazy, late or a liar’ and a successful registrar should be ‘available, affable and have ability’.
One passage that made an impression on me which was as follows:
“BEING AN ACCREDITED ORTHOPAEDIC REGISTRAR IS LIKE BEING IN THE MILITARY. You are expected to work hard, observe rank, get sent to far off places where you might not have the support you are used to, and generally do as you’re told, usually feeling undervalued and exhausted. You are not a registrar forever, and being a consultant is worth it. Besides, the reality is that being a registrar is actually great fun, very rewarding, and very well compensated. It can be helpful, though, if your significant other understands that it is more like being a soldier than being an accountant”.
Traditionally, the expectations were that you arrived at work early every day, saw all your patients before theatre and stayed till the work was done. Half days were a mythical legend and you were in the hospital for the long haul. The role of an Orthopaedic registrar has changed moderately since that document was written. There is less of a military culture thanks to a more encompassing approach to the diverse challenges that registrars face. There is now space for flexible training and a focus on ensuring equality in opportunity. Furthermore, many hospital administrations have made steps to cut costs by reducing the amount of overtime paid to registrars. This has had the effect of enforced reduced working hours, meaning there are times throughout the week you won’t necessarily be on the ground. An additional change is the shift to competency-based training rather than time based training programs. All of this provides a more nuanced set of requirements when compared to the old days of military service. However, what hasn’t changed is the simple fact that the more you see, and the more you do, the better you will be at the end of your training. I would recommend taking every opportunity that presents itself wherever possible as once you’ve passed over onto the other side, the skills that you have acquired will reward you in kind.
Preparation is at the heart of being an effective registrar and maximising training. The goal should be to arrive to each list with the appropriate level of preparation to complete the case independently. This requires planning, communication, attention to logistic details and background reading where necessary. The better prepared you are for cases, the more likelihood there will be of you doing the case and ultimately maximising your skill acquisition. Occasionally, this can feel like service provision rather than training. You do the heavy lifting on the logistics of getting patients ready for the OR and ensuring the equipment is all sorted, then at times the consultant may come in and takes over the case. The better prepared you are, the more likely it will be for the consultant to allow you to get involved in the case. All of this preparation will also help you once qualified as you are accountable to your own patients.
Being on call
On call is an important aspect of registrar training. It exposes you to the unpredictable world of trauma and emergency referrals. The referrals that you receive are your responsibility as the on-call registrar. When you start out, it is advisable to follow the rule that all referrals be personally seen and reviewed regardless of the acuity. Whilst you may not need to drive in to see an uncomplicated referral at 3.00am in the morning, you ideally would see them before the team handover in morning and be across any hurdles that may present themselves for the case. I can think of various times when on physically reviewing a consult, the presenting problem was vastly different from that referred over the phone. More often than not, you will confirm the absence of compartment syndrome or septic arthritis, but occasionally you will be presented with an evolving disaster which would have gone unnoticed without an in-person review. You have to do a lot of on call to get experience with the cases that will test your limits on the other side of training. The rare gems of trauma don’t come around very frequently such as flexion-type supracondylar fractures, talar neck fracture dislocation, multi-traumas or dislocated knees to name a few. You’ve got to be on the ground to get exposure to the breadth of trauma that you will be responsible for managing as a consultant. It’s remarkable how commonly these present when you’re doing sustained periods of on call as a consultant, and you want to be confident in managing them safely to achieve a good outcome when they present.
When you’re on call, remember there is a support network in place; always use it freely and liberally. Almost all referrals should be run past a consultant. Whilst you may be able to triage your referrals and wait for the optimal timing to discuss them, ultimately the consultant on call is responsible for the patient in addition to yourself. You should always formulate your own plan and make the effort to fill the gaps in your knowledge along the way where necessary. This will help to sharpen your clinical judgement. There may be more than one right answer, so be prepared for your initial plans to change and always have a plan B as a backup.
Making a mistake
When you make a mistake - and you will make mistakes - you need to own them. Phong Tran was an incredibly supportive head of the unit during my time as an unaccredited registrar at the Western. He was very clear that we would be judged not by the mistakes we made, but by the response we made to our mistakes. This culture was formative in developing a practice of owning up to your mistakes, learning from them, being honest about how they arose and putting steps in place to ensure that they weren’t repeated. Whenever a complication or poor outcome arises, there will be an impulse to minimise your involvement in the situation. I would strongly recommend not letting this impulse take hold. When you inevitably are involved in a complication, conflict or mishap, don’t diminish your role in what has occurred. Take it on board, speak to the issue directly yourself and don’t rely on others to take the hit. Be proactive and demonstrate that you understand the importance of learning from the mistake and avoiding this from being repeated. My experience has been that your reputation within the unit is strengthened rather than diminished when you own up to your mistakes.
Taking ownership of your patients
As a registrar, it is beneficial to view the inpatients as your personal responsibility. Often, patients are viewed in silos relating to a particular surgeon or registrar’s prior involvement with the case. Ultimately, as surgeons and doctors we are responsible for providing high quality patient centred care, which sometimes is forgotten as our role becomes more surgically focused. Particularly as you become more senior, it will serve you well to ensure you have an overview of where each patient is within the spectrum of their clinical progress. Identify complex patients that have the potential to go south and maintain a focus on them. At times, there may be a junior registrar who has been involved with a particularly challenging case and maintaining involvement in such a case may be warranted. You don’t need to micromanage or take over every case but you should know all the patients on the unit and be ready and available to get involved where necessary. Clear and regular communication with both your junior staff and patients is key to a good outcome for all involved.
Leading the pack
Leadership in surgery is one of those buzzwords that gets a lot of focus. In my view, being a leader is simple: lead by example. Rather than explaining the standards that you think need to be met, meet those standards yourself. You can tell your junior registrars what you expect from them and provide sweeping statements on the ideal way to conduct yourself, however if you don’t back up your advice with actions, the result will be minimal. Do the hard things yourself and you will find things are a lot easier in the long term. As an unaccredited registrar you will be expected to formulate great examples of leadership skills to spout for the interview. Use this opportunity to observe and reflect on the senior leaders that you respect – the overwhelming majority will have this in common..
My experience in training was that surgeons are unbelievably generous in terms of teaching the trade. This is highlighted most acutely during the run towards the fellowship exam. There is a circuit of highly trained specialists who generously give up their time to provide their insights into various subspecialties. Make the most of your training by tapping into these resources. The Australian orthopaedic training stacks up incredibly well internationally. Think early about your career plans, particularly where you want to go on fellowship, and make use of the people that have gone before you to get there.