Continuing our ‘my life as a…’ series this week, we have an anonymous cardiology registrar nearing the end of their specialty training.
Where are you at right now?
I’m in Cardiology, recently started ST6. I’m in the Northern Deanery.
What stage did you decide on your speciality?
In medical school I was considering anaesthetics and ITU. I liked acute presentations, but noticed I also really enjoyed anything to do with cardiology.
My first F1 job was in cardiology, and I loved it. ECGs began to click – and I realised you could read so much just from one little ten second strip! I did some placement and tasters in anaesthetics and ITU to make sure, but I realised cardiology was definitely for me about halfway through F1.
What brought you to your decision?
I value variety. Cardiology has a mix of everything – a mix of patient ages, as well as acute and chronic patients. There’s a nice balance between medical acumen/diagnosis and procedural skill. The procedures have a high chance of being curative or life-saving, which is very rewarding. Conditions which had limited treatments twenty years ago now have significantly improved prognosis and quality of life. I really value my team– nursing, radiology, and physiology staff are essential in cardiology. Their expertise is second to none.
There’s also a nice balance between ward, clinic and procedure work – with a lot of opportunity for teaching or research.
When I was a medical student and junior doctor I wasn’t sure about the procedural side of this specialty – so thought I’d go down the imaging route. There’s a big difference between observing procedures and actually performing the intervention that makes a patient life longer or makes their prognosis better. Procedures are now one of my favourite parts of the job!
Thinking about my time in ITU; I like the medical diagnostics involved in cardiology, whereas ITU and anaesthetics have lots of surgical patients where the diagnosis is pretty self-explanatory. And then they often defer to other specialties to guide investigations or decisions. I wanted to be the person with the specialist medical knowledge. Also, I realised I like explaining things to patients and I like the medical ward round and clinic – something you don’t get so much in ITU.
When I was considering other specialties, I found myself thinking that there’s a less curative impact with many of them. If you consider respiratory – you can’t cure COPD or asthma, and there’s more cancer, which I personally find hard to work with regularly. Gastroenterology and hepatology was probably the closest to compare to cardiology, but the younger patient demographic didn’t appeal so much.
How have you found the exams so far? How did you revise for them?
I started revising for my MRCP in late F1 and sat parts 1 and 2 in F2 year. I did PACES at the end of CMT1/early CT2.
I mostly revised using online question banks and studying on the wards with friends. It’s a lot of repetition and pattern recognition – I quite enjoyed revising for the exams as I felt I was learning so much that was relevant to what I wanted to do. PACES was tough, as you’d expect, but having a good study partner and practising your presentations in the mirror helps!
There is one cardiology specialist exam which is sat usually in ST5 year, and that’s quite clinical. For that, the revision is based around a few clinical text books – but it’s all relevant to what you’ve been doing for several years.
How is your day job split up – when you’re not on-call?
Usually two clinics per week, perhaps a ward round or two a week in a district general hospital setting. The rest of the time you spend in the lab or doing admin.
In ST3-ST5, you’re usually based in DGHs, where you learn core cardiology and train in all cardiac procedures – echo, diagnostic angiography, permanent and temporary pacing, pericardiocentesis and cardioversion. In ST6-ST7, you’ll have chosen your subspecialty of choice, which may comprise:
- PCI (intervention/stenting)
- EP (Electrophysiology)
- Heart Failure
- Adult congenital
Different subspecialties lend themselves to different career trajectories and work patterns, but there is increasing flexibility and improving work-life balance for most sub-specialties.
What aspects of being a medical registrar have you enjoyed the most? What has been hard?
I enjoyed being a medical registrar. I dropped general medicine as it wasn’t compatible with my cardiology training needs and career plans, but some colleagues have made dual accrediting work for them.
I’ve always liked acute medical presentations. My jobs have been in all the main medical specialties, so I felt pretty confident and comfortable with acute conditions. I think people can see medical registrar as a daunting role, but you spend a long time getting experience and its nothing you haven’t seen before – the only thing different is the person you phone when you need help, but help is always there. I think a lot of people see cardiology as the scary specialty, so I think it’s a massive help being on call as a cardiology med reg as you have that extra confidence there. It’s your bread and butter.
I really liked overseeing the junior team, checking their clerkings, providing feedback, teaching, and support.
The most challenging aspect for me was just the length of the shift combined with high intensity work – and obviously, rota gaps. If shifts were 8 hours it would be fine, but it can get tiring being constantly switched on for a long shift, often without a proper break. Bed management was frustrating, having to decide which patients get boarded out and being pushed toward reviewing well patients for discharge over sick patients. I was generally lucky with staffing and having a great team around me.
What’s the best thing about being a Medical Registrar?
Seeing a variety of acute medical presentations, leading arrests, liaising with other teams, flitting about making concise reviews and quick decisions and supporting juniors. It’s also great when you can use your cardiology skills!
What’s the worst thing about being a Medical Registrar?
Rude or obstructive colleagues, mostly.
Could you share with us your most challenging moment so far?
The hardest bit for me is recognising when someone has things under control, or if they need more input or direction from me. Often people won’t tell you or ask! I find it difficult to know when to trust that someone will work to a certain standard, or whether I will have to double check certain things, or if they need additional support.
Once, an A&E reg referred me a man with ‘a UTI’ – the handover was that he wasn’t sick, so I didn’t see him for a couple hours. There were no beds on the ward, so I went to see him in A&E. He’d had a slapdash review hours before and not been checked on again. He was anuric, septic, acidotic – I got him straight to HDU. I felt guilty because ‘I should have known to check sooner’ – but I think the hardest part is that you only know what you’re told. You have to trust the person you’re speaking to, and sometimes they haven’t quite seen the full picture.
How do you deal with an ever-growing medical take list? What advice would you have for managing all the referrals?
I never get too stressed by this. It doesn’t take too long to assess a patient and make them ‘safe for now’. There’s always another team coming on, every shift has an end. Although I tried not to – if there were people to hand over, that was that, I didn’t take it personally.
I learned pretty quickly that the med reg is there to review and offer specialist opinions, have an oversight and keep things rolling. I check up on patient’s progress – I’m not a clerking/jobs horse. I check critical bits of a clerking, rather than repeating the whole thing. I just ensure everything major is sorted before moving on.
I think this comes down to having a good team of juniors. From a leadership side you praise their hard work, delegate, know that some things will have to wait, and communicating that there will be a wait – that usually helps. In terms of prioritising, I generally go to whoever’s likely to arrest soonest – and that usually follows the ABCD pattern. A lot can be managed remotely, so I take advantage of that.
What do you think are the most critical personality traits that a doctor should possess for a career in medicine?
You need to like reviewing patients and medical conditions.
Working conditions, colleagues, and resources change – but the patients and conditions are the one constant. Ability to analyse, rationalise, prioritise and work well with others are all beneficial.
What needs to be done to make medical training fit for purpose?
Staffing has definitely deteriorated, so there are less people, performing generic work.
There’s also been a big reduction in responsibility for juniors – some CMTs have never done anything other than observing bloods, cannulas, and discharge letters for years. They’re not being prepared for registrar work, and this is all about having independent decision-making on ward rounds and in clinic.
Many ward rounds are consultant-led, and everyone is too busy to let the SHO or the registrar take the lead or see patients and present. It’s a key part of learning, and it’s being missed. SHOs are often sent off the ward round to prepare discharge letters.
Personally, I signed up to medicine knowing it would be hard work – and I don’t mind staying late or missing breaks if it means I get to help a sick patient. I think the trouble is that current junior doctors are staying late and missing breaks for tasks that they shouldn’t have to be doing, and they don’t have the satisfaction of being directly involved in patients. A big improvement would be to have auxiliary staff who can do those tasks so the doctors are free to go to clinic, do the ward round, make decisions, review patients, regain some autonomy.
A concern of many trainees applying for medical training is the work-life balance; how do you cope with incessant nights and weekends?
I only get nights and weekends every now and then – and in between on-calls I’m doing a job I enjoy!
It’s better as a registrar – your rotations are longer, you can book leave further in advance, and the work is just different. It’s much better than being a FY or an SHO. I’ve never particularly minded working nights or weekends as it’s what I always expected a doctor would do.
If it’s important to you that you don’t do that, there are other specialties with less on-call burden. There are some subspecialties and career paths within cardiology with an infrequent on-call burden as consultant. So you’re only a reg for five years – you’re a consultant for over twenty, so ask your consultants how often they’re on call. It doesn’t seem so bad to me!
With medicine and training becoming increasingly specialised, is the General Physician dead?
I think there’s an important role for the general physician, particularly in an aging population. I think there is more need for geriatricians and general practitioners.
But it would be hard to justify a 40 year old with new heart failure staying under a general medic when so much evidence shows a difference in outcomes when people are managed by the appropriate specialty. It’s been proven over many medical specialties, not just cardiology. That being said, not every pneumonia patient needs to go to respiratory!
With cardiology, I notice there is little exposure among FY/CMT/med reg and GIM consultant to these patients. The threshold for specialist advice is low. They’re understandably nervous about risk stratification and management. I think it would be impossible to take specialist cardiac input away from these patients.
There’s a greater need for the generalist when it comes to triaging, or assisting with complex medical patients – particularly reviewing patients with common medical problems on surgical wards. When I think of patients a general medic might look after, I think of the patients who get boarded out, or who go to winter pressure wards. Usually infections, constipation, fluid issues, people with a plan from the parent specialty but who just need time, or awaiting physio.
I’m personally very against the current boarding system – I think having a dedicated ward and an allocated team looking after these patients is essential. With increasing admissions in need of general care, maybe there’s a call for a general medical ward for these patients. However, I’m not sure the way doctors are being trained into specialties is setting us up to do this sort of job as a consultant.
What’s the best and worst thing about your specialty?
The best thing is definitely the impact you and the team can make on patients prognosis. Someone comes in with heart block and syncope; a pacemaker takes a couple hours to put in, cures the heart block, treats their symptoms, and they can go home later that day. I don’t think you get that sort of immediate reward in many other specialties.
The worst thing… maybe getting phone calls about slightly raised troponins and it shouldn’t have been taken in the first place. Maybe 5 calls a day for that one!
What’s your number one piece of advice to junior doctors who are considering applying for medical training?
Choose which patients or conditions you like to see and go where they are. See which specialty fits that.
Don’t be put off by things that seem ‘too hard’ – you don’t become a consultant overnight and you’ll have years of training in a specialty. And even then, you aren’t expected to know everything!
For those applying to cardiology, try to spend time in cardiac placements and taster weeks to see the procedural and acute side where possible. There are plenty of course and echo/ECG training events which can boost your application.