Junior Doctors

The plight of the Pre-SET registrar

Happy Monday everyone. I’ve just returned from a weekend in Perth where I had the privilege of being part of the Western Australia (WA) Department of Health forum for Surgical Service Registrars, held at Fiona Stanley Hospital (image credit: Peter Bennetts). For the benefit of those who could not attend on the night, and for others around the country/world who are interested, I thought I’d share my presentation and the discussion points from the break out sessions.

The session was attended by the CEO of the Royal Australasian College of Surgeons (RACS) Mr John Biviano, members of the WA Health Medical Workforce, including Manager Ms Gillian Munyard and Medical Advisor Dr Paul Myhill, Chair of the Post-Graduate Medical Council Dr Marg Sturdy, consultant surgeons, including RACS (WA) Chair Dr Mary Theophilus, Prof David Fletcher, Dr Ian Gollow and Dr Stephanie Chetrit, and of course pre-SET registrars working in WA.

I’ll refer to Pre-SET registrars as ‘we’ even though I am no longer one. I choose to continue advocating for this space because I feel I would be a hypocrite not to. During my difficult term last year, I kept thinking to myself, “Why didn’t anyone before me say anything about this terrible term?” The answer is, they couldn’t. Therefore, now that I’m in a position where I can say something without fear of repercussion, I will.

I’ve deliberately used the term Pre-SET in this article. I remember an anaesthetist referring to me as the “Pre-SET” registrar and thinking to myself how nice that felt. It made me feel hopeful that I was on the way to becoming a SET registrar. Let’s discuss the title of “Unaccredited” or “Service” registrars. Words do matter. “Unaccredited” highlights the fact that we are not on training yet, which hits a sore spot. It can also make us feel inferior. “Service” Registrar implies that the registrar is there to serve, and only serve: a slave to the public hospital. This brings me to what I think Pre-SET registrars deserve:

  1. Supervision and education
  2. Wellbeing
  3. Safe working hours

Supervision and education

Governing body & representation

Pre-SET registrars are a voiceless and vulnerable population in the hospital system. We are waiting to get onto training programs, which relies on good references, therefore we are reluctant to say anything, as we do not want to be seen as a trouble-maker, struggler, or complainer. We do not have a governing body that is external to our hospital units that can administrate feedback about our terms.

Accredited registrars belong to the College. Interns and residents belong to a post-graduate medical council, which has various names around the country – e.g. PGME (WA), HETI (NSW), PMCV (Vic). Who represents Pre-SET registrars? No one. We had a discussion as to who would look after us. There was a divide at the forum – most seemed to feel that PGME would be appropriate, whilst others were concerned that there had previously been pushback from PGME. There was an impression that PGME was already overwhelmed with having to look after interns and residents. However this is a logistical and staffing issue, and the solution would be to have a dedicated team within PGME for the Pre-SET space.

In WA, there is a Service Surgical Registrar Employment Advisory Committee (SSREAC) which has existed for three years now. One issue identified was that this committee was not known to many of the registrars. It is therefore important for SSREAC to be more visible and engage directly with Pre-SET registrars. One motion from the forum was that a Pre-SET representative should be elected onto the committee. SSREAC is responsible for recruitment of Pre-SET registrars, and is currently trialling a feedback form.

Formal feedback

Feedback was identified as an important issue. This is bi-directional; registrars should be able to receive formal mid- and end-of-term feedback about their performance, as well as give feedback about the term. At the moment, registrars feel that they cannot give honest feedback about the term because if their criticisms can be traced back to them, it has a potential to affect referee reports. Thus, there needs to be an external governing body that can collate feedback forms and then anonymously present the feedback gathered over the year back to the units.

Whilst accredited trainees have an appointed Supervisor of Training who is responsible for completing compulsory mid- and end-of-term feedback forms, pre-SET registrars do not. It is hard to obtain feedback because most doctors find it difficult to give feedback, especially if there are any criticisms. For consultants to take feedback seriously, and give pre-SET registrars constructive criticism and a realistic view of their performance, feedback must be formalised.

The benefit of having a formal supervisor for a pre-SET registrar not only includes a means of receiving feedback, but also a point of contact for the registrar. Whilst we appreciate having a supportive consultant, that consultant cannot always advocate for us. In particular, if there is an issue between a pre-SET registrar and a consultant, it would be difficult for another consultant to stand up for the registrar against a consultant colleague without a formal role to facilitate a mediation.

Having a formal supervisor also means that there is a consultant with whom goals for the term can be identified and monitored throughout the term. One issue raised by the forum was that units do not have an introduction to the term. An introduction would serve to:

  • Identify the level of experience of each of the registrars, which helps to delegate tasks appropriately
  • Let registrars know what the expectation of the unit is (for example, doing a research project during the term, being able to do certain procedures by the end of term)
  • Allow registrars to voice what their expectations and learning goals for the term are, and how that may be achieved. This includes selection criteria for SET that they need to fulfil during the term.

The forum also acknowledged that a supervisor, assessor and mentor are three different roles, which should ideally be held by three different surgeons, which is not always possible.

Formal and informal education

It is in the interest of both the registrar and patients that we are given ongoing education and training. Formal, protected teaching can be difficult for pre-SET registrars to attend, as often we are the ones carrying the pager, however consultants at the forum acknowledged that informal teaching-on-the-run was important. One way to give pre-SET registrars an opportunity to learn in theatres is for a consultant to take the pre-SET registrar through a case that the accredited registrar is already familiar with, and has enough of in his/her logbook. By training pre-SET registrars, patients also benefit because they are being looked after by someone who is directly learning from consultants.

Wellbeing

How many doctors have to die before we take this seriously? Over-working and bullying doctors has a tremendous impact on doctors’ health and wellbeing. I briefly talked about the impact it has had on my health, even now, fourteen months after I resigned. We are all familiar with the bio-psycho-social model of health. We often focus on the biological aspects, but we don’t even get to look after basic needs like food and water. Sometimes we forget that doctors are humans and we deserve to be treated as such. As humans, we are multi-faceted and we have psychosocial needs too, which are often dismissed as being ‘soft’.

Does anyone remember playing The Sims?

Bio

  • Food
  • Water
  • Sleep
  • Hygiene
  • Exercise

Psycho

  • Free from bullying & harassment – is #OperateWithRespect working? Is it lip service, or will we see results?
  • Access to mental health services – Yes, all doctors should have GPs, but when do pre-SET registrars ever get time off to see one? What if we need psychology sessions? How do we fit that around a surgical on-call roster?
  • Reduced stigma about mental health
  • Being able to debrief with a mentor – it is the nature of our jobs that we are exposed to human tragedy, traumatic scenes, and we make mistakes that can leave us feeling guilty or scared.

Social

  • A life (!)
  • Quality time with family and friends
  • Relationships
  • Hobbies (what is that?)
Humans need fun, and we shouldn’t feel guilty for wanting to do something fun!

Doctors look after patients, yet we don’t look after ourselves. For us to look after ourselves, we need time to do so. Working unsafe hours not only means we are suffering from the effects of chronic stress and sleep deprivation, we don’t have any spare time to do things that are healthy for us. Therefore, an obvious solution is to make working hours and rostering fair and safe.

Looking after doctors’ mental health is receiving an increasing amount of attention. RACS has put in a tremendous amount of work into their #OperateWithRespect campaign, which is highly visible. However, it takes more than a campaign and a catchy hashtag to make change – it must be operational. I must say, it does anger me to see the hashtag misused. I want to see bullies caught out for their behaviours, but I am seeing it used for nit-picky and pedantic issues online. Just like any other political issue, political-correctness can sometimes become excessive to the point of absurdity. The power and impact of something gets diluted when it gets overused, to the point where now I am paying less attention to things tagged with #OperateWithRespect because it can be used for anything from sexual misconduct to the wording of a sentence.

Back to the actual campaign. Anecdotally, we have all seen surgeons who watch the compulsory video and don’t think that the scenario is an example of ‘bullying’. Others condemn the bullying in the video but then go on to exhibit bullying behaviours themselves. I understand that RACS is rolling out the new phase of #OperateWithRespect and will be re-surveying members of the College to see if there has been any noticeable change in the workplace culture. I look forward to seeing these results.

Safe working hours

A lot of work that we do is unrecorded or unrecognised. Most of us are happy to work overtime, but often feel that we are not valued. Rosters are often written by accredited registrars who take advantage of pre-SET registrars just because they can. It is the responsibility of both the approving consultant and medical administration to ensure that the roster being distributed is fair and safe. There are safe working hours guidelines published on both the AMA and RACS websites, but these are simply guidelines and hospitals don’t always follow them, because they are not enforced.

Another issue raised by the forum was the access to leave. It is difficult to ask for leave when SET registrars are prioritised for their study and conference leave. Some registrars commented that even getting time off for RACS courses such as EMST was very difficult.

Sleep disruptions during on call can be harmful to functioning the next day, and we are reliant on the goodwill of the consultant as to whether we are allowed to take a break or even go home. Sleep disruption is more harmful than short duration of sleep, and both are as dangerous as being drunk at work. Yet, sleep-deprivation is not taken as seriously as drug and alcohol consumption. To allow registrars to recover sufficiently from on-call, rostering should be reviewed regularly, and if possible, a back-up person available.

Workplace reform

Due to the response to doctor shortages, predominantly in rural areas, Australia has had a medical student tsunami which has had an impact on job numbers. There are several bottlenecks in the system – internship positions, progression to a pre-SET job, getting onto the training program, and even public appointments for consultants once training is over. There is a limit to how many accredited positions each unit can have for several reasons, including the dilution of case load if there are too many trainees. Whilst I recognise that existing accredited units cannot necessarily increase the number of accredited registrars they can train, I wondered whether the College could look into accrediting more units? Are there regional/rural or private hospitals that have the infrastructure, case load, and consultants willing to supervise and train registrars, that could become accredited units?

The idea of abolishing the Pre-SET registrar role altogether has been brought up previously. Is it time to revisit this? A lot can be learned from the US and UK models of post-graduate training. When a doctor is matched into a streamlined position after medical school, they are given a spot until the end of training, with all terms accredited towards their final fellowship. The UK’s parliamentary inquiry into medical workforce a decade ago – Modernising Medical Careers (MMC) – has produced a number of insights that we could learn from. A registrar at the forum recommended reading the documents on the MMC, which are freely available online here, here, and here. They are all quite lengthy, but there is also a short editorial by Delamothe in the BMJ “Modernising Medical Careers: A Final Report” BMJ 2008; 336; 54-5, which explains the model and its shortcomings (including the oversupply of applicants, which will also be an issue here).

Final thoughts

The WA forum offered a rare opportunity for pre-SET registrars to engage directly with consultants, government, and PGME in an open dialogue about the issues that we face. None of the issues are new. They have been known for a very long time, but it is great that they can surface openly rather than being swept under the proverbial rug. What I experienced last year was unfortunate, and whilst it was the hospital that gave a public apology, one of the surgeons there recognised that, really, the treatment I was subjected to was perpetrated by surgeons who are fellows of the College. I am not one to play the victim or hold grudges. I have moved on with my life to try and enjoy the new opportunities that I have been given, but it really means a lot to me when surgeons stick up for me like that – thank you.

Many thanks to Dr Mary Theophilus for advocating for Pre-SET registrars. Without her, this event would not have been conceived. Thank you to the Office of the Chief Medical Officer for putting on the event, and in particular Ms Gill Munyard for organising everything. Thank you to the registrars and consultants who attended. Without registrars who are willing to speak up about the issues, and consultants who are willing to listen and advocate at the higher levels, nothing will change for the next generation. I look forward to hearing the outcomes from this event, and I am interested to know what others think of the issues and possible solutions. Please feel free to add your comments to this blog post.

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