I recently attended the excellent EMTA18 conference, and I was asked to give a 12 minute presentation on the transition from ST3 to higher specialty training (HST). Here is the blog version of that talk…

The ST3 to HST transition is a watershed moment in the career for all EM trainees in the UK. It marks the graduation from SHO to registrar, and that new label feels significant. I have had “registrar” written on my name badge before when I was working in Australia for a couple of years after F2, but they give any junior doc with a few months EM experience that job title so it felt a little bit like I was pretending(!).

Indeed, “graduating” ACCS (i.e. years CT1, CT2 and ST3) has made me feel (more) like a proper grown-up. The sense of accomplishment and additional responsibility are palpable in equal measure. It’s worth noting that I was one of the few EM trainees in the UK to have all 3 of my ACCS years in the same hospital and, therefore, the sensation of my professional landscape transforming around me has been particularly profound.

Sure there was the occasional bit of “acting up” as an ST3 but I was knew deep down that I was just rehearsing. Senior people were always close by to bail me out if required.

Changes to my day at work that will be applicable to all EM trainees:

• Taking charge of the department overnight (they call it being the “Medical Controller/MC” in my current place)
• More regular clinical supervision of juniors
• Attendance of meetings with important people
• Taking a more active and decision-making role in clinical governance stuff

There will be plenty of info out there with guidance/tips on how to negotiate these new challenges from people far more qualified than me. I thought a more interesting approach to this talk/blog would be to share 3 reflections I’ve had as I’ve gone through the process. Of course, they are unique to my experience, but they have been pretty huge realisations for me and will no doubt be instrumental in shaping the future of my career… and my life in general.

I found ST3 a major slog, particularly having spent CT2 as a supernumerary anaesthetics/intensive care SHO. I spent that year re-acquainting myself with a reasonably normal working pattern and enjoying luxury of grabbing a few hours of sleep when working nights. The commencement of ST3 saw my nose being firmly re-attached to the grindstone, particularly with my first 6 months in the paediatrics ED which I found to be a far more relentless style of EM.

By the end of ST3 I found myself in a state of physical and cognitive exhaustion. In July I got back from a particularly busy family holiday in the US with multiple States visited and was due to start a stretch of nights the evening after I landed. Despite dosing myself up on industrial-strength American sleeping pills I struggled to sleep on the plane and when I got home. I started those nights like a zombie and I don’t feel like I got any deep sleep the entire stretch – I’ve never felt so physically damaged.

I never really recovered from that insult, and proceeded to encounter further bruising from a series of cases I was involved with in the week of days that followed. These included:

• Making a mistake that may have resulted in an adverse outcome for a patient.
• Two unsuccessful prolonged paediatric resuscitations.
• Informing two young adults (and their entire immediate families) that they almost certainly had an underlying cancer diagnosis, and that their prognosis was potentially very poor.

I was emotionally maxxed out, physically exhausted and sleep-deprived. I turned up to work one morning and got told by the boss to cover resus. As soon as I walked in I felt completely unable to do the job. I knew I was an unsafe doctor in that moment and tearfully asked the boss for permission to go home. I took 3 days off sick and during that time I realised that I was dangerously close to having a full breakdown. During all of this I became acutely aware that my transition to ST4 was imminent and that gave me a sense of dread.

I knew that I needed to make some changes. I contacted my new Educational Supervisor and Training Programme Director and explained the situation. I requested a month career-break for August (my first month there) and it was immediately granted. I was overwhelmed with how understanding and supportive they were. They recommended that I put in an application for 80% Less Than Full Time Training (LTFT) – which I did.

I was able to return to finish the final fortnight at my ST3 department knowing there was light at the end of the tunnel, though it was tough. Each shift felt like a marathon. I got through it unscathed though, and spent my month off spending quality time with my wife and our friends, re-acquainting myself with exercise (mainly hot yoga), and optimising my sleep hygiene (which remains a work in progress). Midway through August I got an email informing me my LTFT application had been granted. The sense of relief (even though I didn’t even realise this was an option for me a month prior) was intense.

I’ve started ST4, albeit a month late, with a renewed enthusiasm for the job, and feel like I’m giving pretty close to the best version of myself to each shift. I also feel keen to show off my colourful feathers at work (blog, podcast etc), whereas previously I’d been purely in survival mode.

There is still plenty of room for improvement in terms of achieving an optimal lifestyle for safeguarding against emotionally maxxing out, but I certainly feel that I’ve moved my mental health up the priority list.

Is this realisation specific to the ST3 to HST career transition? Of course not, it can happen at any time in one’s career. Having said that, a considerable source of the paralysing anxiety was regularly remembering “Shit, I’m only half way through”.

This phase at work has revealed, in dramatic fashion, the fragility of my mental health. The experience has been frightening but amongst the most important of my life. I am certain that the structural modifications to my professional and personal life are critical to the longevity of my career in EM and, more crucially, my (and my loved one’s) overall happiness.

For better or for worse, I’ve always prioritised being “mates” with my juniors (F1s, F2s, CT1s etc). During my ST3 year I found myself deliberately snubbing the “senior persona” as I was afraid of sacrificing the informal, hierarchy-free camaraderie that I derive so much enjoyment from. I’m sure it’s mostly a reflection of my sociable nature and an innocent enjoyment of friendship with a group of people I feel a reasonable amount in common with… but I’m sure it’s also a desperate (and rather tragic) clinging to my youth!

The transition to ST4 has introduced a subtle but significant change in this arena. My relationships with juniors remain friendly, but there is distance between us now, both in terms of job description and how it feels during a conversation.

I’m actually chatting with my juniors on the shop floor more than I was last year, but that’s not because I’ve become more interesting, it’s because I’m being asked for advice (and my surname in the patient notes) more often. Our conversations have become purely transactional.

More than any other change in my day at work, it is this shift in my workplace relationships that has most clearly signalled that I have made a big jump forward in my career and now have a much broader range of responsibility.

Despite it being fairly sad to no longer be “part of the gang” (I didn’t get invited on to the F2 Whatsapp group this year), I’ve rapidly become comfortable in the registrar persona. I’ve found it surprisingly straightforward to ask F2s what their plans are for patients they’ve clicked on, or ask them to stop socialising on a night shift when there is a 3.5 hour wait, or sternly enquire why a particularly unwell majors patient hadn’t been discussed with me earlier in the shift. I would never have dreamt of having these kind of conversations last year as I didn’t want to jeopardise friendships… and there was always a middle grade available to do the dirty work.

Of course I was giving clinical advice to juniors as an ST3, but it felt far more informal. Had you asked me last year I would have said that a shift in my relationships in this regard was one of the things I was looking forward to least. But it has felt natural and seamless, which I could never have predicted. I have replaced the desire to be everyone’s friend with the desire to be a role model, and a doctor that the juniors think is good at their job. Being a likable bloke is a bonus. Each time I have a transactional conversation with a junior colleague it serves as a useful reminder of my new position, and nudges me to act with maximum professionalism. It’s regular signposting that I’m now a grown-up.

I’m sure this reflection is common to people across a range of careers where a ladder must be climbed. For me, it feels like the shift occurred overnight. Despite its rapid onset it feels like one of the most important and permanent adjustments to my thinking patterns that my career will ever see.

So it’s not just the changing conversations with juniors that have flagged my professional expansion. I’m being treated with more respect by everybody in the department, from the nursing students to the Consultants. Again, I guess that is par for the course when one nominally transitions from junior to senior.

I’m being asked to attend meetings with lots of important people, like senior faculty meetings, MDTs and trauma steering groups. And when I decide to stick my neck out and contribute something at one of these meetings, those important people actually listen to me (unless I say something particularly brainless).

In handover meetings after finishing a night shift, any residual small tasks get hoovered up obediently in an instant by the day team. Last year I would have done those tasks myself and stayed at work for a painful extra half hour.

When combining this new level of respect that I seem to be receiving with the sense of accomplishment having completed ACCS, along with getting my work-life balance semi-sorted, I’ve found my workplace Mojo to be at an all-time high.

This increased Mojo has manifested as three positives and one big negative.

Positives:

• I’m trusting my decision-making more implicitly. Fewer worries about patient’s I’ve sent home etc.
• I’m throwing myself into teaching more than ever because I feel like I actually have some knowledge that would be useful to transfer into the brains of juniors/med sttudents.
• I’m getting myself into the mixer in resus and honing my team leadership skills at every opportunity. I’ve led more trauma calls and cardiac arrests in 3 months than I did my entire ST3 year.

Big negative:

• There have been occasions where I’ve got drunk on my own self-importance and been rude to colleagues.

In the thrust of managing a crashing patient with flash pulmonary oedema in resus 2 weeks ago, I gave both barrels to the junior intensive care doctor for suggesting a Ddimer. And just last Friday I got into a very public row with the medical registrar for not immediately accepting my referral of an 80-year old lady who came in after a presyncopal episode in the supermarket with a trifascicular block on her ECG (which I was particularly pleased with myself for identifying… and so insisted on showing the nearby F2 how knowledgable I was by insisting on some ECG teaching… *cringe*). I got very agitated on the phone in full earshot of several patients and their families. I put the phone down and immediately felt ashamed of my lack of professionalism. I promptly called the guy back and apologised, which was fairly humiliating. The finger of blame must be pointed squarely at the recent Mojo infusion!

All of the Consultants I look up to the most have an ability to keep their necks wound in regardless of the situation. No matter how pressurised the moment, how overwhelmingly in the right they are during an argument, or how much abuse is being thrown at them, they stay calm and collected. As a result, the outcome of most situations in which they are involved tends to be favourable, no matter how dire the circumstances. Each of them has the ability to harness their enormous Mojo and apply it where needed and not where it has the potential to cause harm.

As I transition from ST3 to HST I have been entrusted with increased power. I am able to make things happen more effectively and deliver better care to my patients than ever before in my career. But a priority for my development must be to control my enthusiasm and engage my Type 2 brain as often as possible, as that power can turn rapidly into a toxic ingredient in an already high octane workplace.

Robbie Lloyd
@Ponder_Med

*Credit to Mr Bingo for slide design