Episode 28: Transitions to Fellowship
Episode 28: Transitions to Fellowship
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The transition from trainee to consultant marks an exciting and daunting step in a clinician’s career. Suddenly you take on responsibility for everyone on the ward—both patients and other staff. And while clinical skills have been hammered in over years of training, the ‘hidden curriculum’ can be harder to pick up. The College has recently published How to Thrive as a New Consultant, a handbook to help navigate this period with confidence.
For today’s show, guest producer Zacha Rosen spoke to four physicians who look back on their transitions, from six months on to nine years on. They capture the experience of striking out as a leader, manager and mentor to others. At the same time, one doesn’t need to have all the answers. Recognising limitations and knowing when and how to seek help is all important. This is equally important in the clinic and in regards to one’s own wellbeing. The speakers in this episode describe how they maintain a healthy balance within and around their careers.
Guests: Dr Marion Leighton FRACP (Wellington Hospital), Dr Martina Moorkamp FRACP (Mercy Hospital for Women, Melbourne), Dr Lawrence Ong FRACP (Westmead Institute For Medical Research), Dr Ben Vogler FRACP (Cairns Hospital).
How to Thrive as a New Consultant
New Fellows Orientation Guide
Support Program Helpline
Healthier Physicians Checklist
Health of Doctors Position Statement
Support Services for Health Professionals
Meeting the Non-Clinical Education and Training Needs of New Consultants [BMJ]
Understanding the Transition from Resident to Attending Physician [Academic Medicine]
Junior Doctors Caught in the Clash: The Transition from Learning to Working Explored [Medical Education]
The Transition to Hospital Consultant and the Influence of Preparedness, Social Support, and Perception [Medical Teacher]
Working as a Newly Appointed Consultant: A Study Into the Transition from Specialist Registrar [British Journal of Hospital Medicine]
In at the Deep End: Making the Transition from SpR to consultant [Advances in Psychiatric Treatment]
This episode was produced by Zacha Rosen, with research assistance from Beverly Bucalon, and hosted by Mic Cavazzini. Recording in Wellington by Ryan Smith. Music courtesy of Lee Rosevere (“Thoughtful,” “Here’s the Thing”), Chris Zabriskie (“Wonder Cycle”), and Rosie Catalano (“Waiting”); photo copyright RACP. Pomegranate Health’s executive producer is Anne Fredrickson.
Editorial feedback was provided by RACP Fellows Dr Michael Herd and Dr Rebecca Grainger.
: Welcome to Pomegranate Health, podcast of the Royal Australasian College of Physicians. I’m Mic Cavazzini.
The transition from trainee to consultant marks an exciting and daunting step in a clinician’s career. Suddenly you take on responsibility for everyone on the ward—both patients and other staff. For today’s show, guest producer Zacha Rosen spoke to four physicians who look back on this transition, from 6 months to 9 years on. The College has recently published a handbook to help navigate this period with confidence, and find support when you need it. It’s called How to Thrive as a New Consultant
. One of its authors was general physician Marion Leighton.
: I’m Dr Marion Leighton
and I work as a consultant physician at Wellington Hospital. I was instrumental in the first general medicine peer group here in Wellington and in writing the How to Thrive as a New Consultant
guide. When we were writing the new consultants guide the first time around it was part of my peer group, which was ten new consultants. We shoulder-tapped each other and established the peer group because we knew it was something we wanted to do and we knew we needed support from each other around aspects of being a new consultant. And most of the peer group work was discussing difficult patient situations, so complex diagnoses or how to get different investigations or what we should do next with a patient situation.
But we found we were talking more and more about how we got on with our colleagues, how we talked to each other, how we referred patients. When we wrote the first guide it was very practical; it was very “how to ward around dealing with a complaint,” we had “how to set up a job,” “making sure you talk to your local union.” By the time the second guide came around we’d realised that while that stuff is really important and you do need to know it, the other more intangible stuff of how you get on with your colleagues and interact with people both below you and above you, so to speak, in the hierarchy is very important.
The practical skills are very important and I don’t think the new consultants guide is trying to suggest that they are not. The difference is that you’ve spent six to 10 years in training, learning those practical skills. By the time you’re a consultant you should be pretty good at those practical skills, so those aren’t the new skills you need to learn when you become a consultant.
I find medicine a very interesting profession in that while we care greatly about the clinical skills, developing those clinical skills, they are difficult and they need a lot of expertise. However, the non-clinical skills are actually the things the patient sees. I don’t think patients really care how good we are at doing the clinical skills because they expect a certain level of proficiency—“If I have gone to see this doctor and this is their speciality, they will know that stuff and I don’t need to know about that.” “But what I care about in my doctor is how well they talk to me, how respectful they appear to be to the rest of the team, to the nursing staff, whether they phoned my family member, whether they can also diagnose and treat my itchy skin rash when I come into hospital rather than just my pneumonia— because, in fact, the skin rash is the thing that’s been getting me down for the last 3 years but the waiting list for dermatology is 3 years long and I can’t get on it.”
And so it’s the little things; the things that as doctors we often think are peripheral because we’re concentrating on the clinical skills that actually make the difference to the patient.
Your clinical skills need to be 100 per cent; I’m not in any way suggesting they don’t. But your non-clinical skills also need to be right up there. The hidden curriculum is a metaphor for all those things we don’t get taught, so a lot of the things like how to make relationships, how to engage with the culture of your organisation as well as the culture of the country or the place you’ve just moved to. It’s the things that you suddenly realise you’ve said something and everyone else has gone quiet, and obviously that wasn’t the way it was supposed to have been received or said—but no one told you that—“That’s not the way we do it around here.” It’s learning on your feet, but it’s also being open to other people’s advice, open to new ideas, and it’s a lifelong learning. You’re never going to have complete grasp of the hidden curriculum because it’s not written down.
: Something that’s caught rather than taught. My name is Martina Moorkamp. I’m a neonatal consultant and I’ve been working at the Mercy Hospital for Women for the past 9 years, and I became a specialist in the UK. I got my FRACP by going through the OTP pathway.
I think if you have a positive culture and good environment what that can take away from the hidden curriculum is how to treat each other properly, how to hopefully have a good role model and say, “This is maybe the person I would like to be like in 5, 6 years as a consultant.”
I think it also depends on what sort of environment you work in, what sort of team you work in, what sort of culture you’re working in, what is your support group like, what are your colleagues like, are they prepared to support this new, fledgling sort of junior consultant, answer their hundreds of questions of “I’m not quite sure what to do.” Are they prepared to stay on a bit longer if there’s a difficult case and they know that this person needs the extra support?
: In terms of developing the bravery to ask senior colleagues for help, my experience now is just do it. Pluck up the courage and just pick up the phone or send the email. If you ask people for help they are very likely to just give you the help you need and be very generous with it. I think there is more and more evidence now that having a mentor is of crucial importance to all professionals and across business organisations, other professional organisations as well as medicine.
Mentoring is a fantastic way to help guide you through your career at all stages and I’m very keen on people having mentors throughout their career. And you can choose different mentors at different times. You might have a mentor for two or three years and then your life or their life moves on and you don’t need their set of skills as much anymore. Mentors that I had ten years ago, only one of them I would say is still a regular mentor of mine, and now I have other people who I use as mentors and other people I am a mentor for.
: I would advise every new consultant to choose a mentor, and I think that’s completely different from the College supervisor. Somebody that you choose yourself, somebody you really click with and meet up with. It’s somebody you can discuss things with that could be potentially clinical things but also things that you find difficult to cope with at work, maybe situations that you’ve found difficult to deal with. And it should be a person that you look up to, a more senior person, maybe a role model, somebody you find deals well for things that you might not deal with yourself. Somebody said, “A mentor is part warm, bath part cool shower.” That mentor needs to be also very open and honest with you.
: Overall I think the main benefit is you are getting the experience and the advice from someone who is different to you either because they’ve been in the game longer than you have or because they’re coming at it from a different perspective and a different specialty. I think having mentors who are your immediate peers is really useful, but having mentors who are people who are not like you is also vastly important in a career such as medicine where you’re going to be doing things that don’t always feel comfortable on a fairly regular basis; there’s always something to talk about.
: My name is Lawrence Ong. I’m a consultant clinical immunologist who recently received my Fellowship in February of 2017. I’m also a PhD student at the Westmead Institute for Medical Research, researching the immunogenetics of multiple sclerosis.
I’ve got fantastic mentors, I guess I’d call them. I don’t have any hesitation in asking them for advice if I need it. Naturally you’ll gravitate towards some consultants because of personality; you just get on well with them. You find them easy to talk to and show that you’re keen and would appreciate their input and their assistance. You just have to put yourself out there, and it might seem a bit strange at first. I found a lot of my consultants were more than willing to help and give advice along those lines. Nothing is better than having that experience there behind you.
: Whenever I have any particular worries or problems or I’m not quite sure where to go, there’s always somebody here whom I can trust and ask and rely on to give me a hand or help me. Now, that might not be the case everywhere but I work in a workplace where this culture has been cultivated of mutual trust and understanding and support. I am never too worried to ask my colleagues what they think, and I still do that to this day. Yeah, I’m not too above myself to do that.
I think that’s very good advice and I feel always suspicious of juniors who will never, ever when I’m on with them ask me or ring me and ask me for advice.
: When you become a consultant suddenly you are the one in charge, or certainly the perception is that you are the one in charge. However, I think we also have to be cognisant many patients have conditions that they’ve been living with for a long time and are experts in their own condition. And also your registrars may be sitting their exams at the moment and they certainly know a lot more about certain things than you do. And your senior colleagues will also have opinions and senior colleagues may be seeing the patient in another aspect of their illness or for a different comorbidity and have opinions over what choices you make or don’t make.
So although, yes, at the end of that specific patient interaction you get to call the shots, you aren’t as in charge as you probably think you are.
Our job as consultants is to help people grow their own skills and become more empowered and better able to do their job so that we can all do it together. You also, as a consultant, have to learn when you have to give things up. You’re no longer a registrar and you have to leave your registrar to do certain things on the ward and to make their own mistakes and you have to be able to live with those mistakes at times, and usually it’s OK—there’s more than one way of doing something. And you’ve got to be able to step back and take a deep breath and remember that it’s only your blood pressure that’s going up, not everybody else’s. But in the actual throes of the event you support your team and you go into the situation supportive of everybody’s actions.
You know, I often say something like, “Now, that was exactly the right thing to do at the time but I think now we have a little bit more information and we’re going to do something a little bit different” –particularly to the patient and family or to the nursing staff, not being seen to undermine the registrar or the house surgeon or the person who’s usually doing their best even if they aren’t doing it as successfully as you’d like them to do. As a consultant often your job is to be the calmer-downer. If the situation on the ward has spiraled out of control a little bit and tensions are running very high you can be very effective as someone who can step in and calm the waters and say, “That’s okay. It might not be what I would have done, but I’m happy with the outcome and I’m happy that this is the direction we’re going to go in.”
: It’s only recently workshops or courses have existed for people to develop those professional skills, as opposed to purely on-the-job training. And you can see how on-the-job training, if it doesn’t happen it can leave a fairly large hole in someone’s skill-set.
: My name is Dr Ben Vogler, I’m a general and acute physician at Cairns Hospital and I became a Fellow of the College approximately three years ago.
Some of the best advice is to think quickly and talk slowly, not trying to be the main voice in a room, try to hear what other people are saying. Essentially just to keep calm and not to escalate conflict further.
: I remember in my first year as a consultant, coming across a diagnosis I had never ever come across before. And the patient was very sick; they looked like they were going to die. The intensive care unit was completely full. But I knew I needed to do more than were able to do here on the ward. I knew what I needed to do, but I couldn’t do it by myself.
I rang up the intensive care unit and said, “I need this patient to have a central line. But if you can come and put a central line in on our ward in the treatment room, I can probably manage the rest of the treatment here in our high-dependency unit.” Because they knew me, and I’d made these connections and things, they did come over and help. And then I had the problem that I was giving this person a very dangerous drug, that if I was wrong in my diagnosis, it could make him much worse.
I rang back the ICU that evening—a new registrar was on—and said, “This is what I’m going to do. I need you to be able to help me.” And he said, “That’s a really rare diagnosis. If you’re wrong, the patient will go into respiratory arrest.” To which I said, “Yes, if I’m wrong, I’m going to need to phone you very quickly and get you over here immediately.” To which we all laughed, but they got themselves ready, so that if I was wrong, they were able to help.
Now having the courage or the guts and the realisation that I needed other people to be there on standby if it went wrong, was the main part of making sure that patient was successfully treated. And the way I got through the process was actually by using my communication skills, it wasn’t through knowledge. It’s important, I think, to have a range of different ways of thinking and behaving. Sometimes you need to slow your thought processes down and be quite honest and say, “I don’t know what’s going on here; we need some time to think about it.”
Another key thing in medicine is being able to do nothing, and sometimes the right thing to do is to take a step back and do nothing for a while and keep an eye on things and see how things pan out, and that’s definitely a skill to be learned as a consultant is when you just observe rather than jumping in with two feet. Doing nothing is one of the hardest things we do in medicine. A colleague of mine describes it as, “Masterful inactivity with cat-like observations.” So, we’re keeping a very close eye on the situation, but we’re actually going to do nothing but in a masterful way.
Work/life balance is flavour of the month at the moment, and I do think it is vitally important. You can’t do a job like medicine without having other things going on in your life. And a job like medicine also will grow to fill the space available to it. So, if you continue to work late and you take work home and you work at weekends you will continue to have more and more and more. The only person who can set boundaries around your workload really is you.
: Work/life balance is obviously very important, not just as a throw-away phrase, but if you think about your day-to-day functioning as a human being, having a balance just gives you that sense of wellbeing and that energy to push on and to really do what you want to do at the best level that you can. Many of us will have families or be having families or be neck-deep in home loans or whatever, but it’s important to be able to step back at some point and just to look at what you’re doing and be able to say, “Look, amongst all this time I must prioritise this, this and this, and I must have time to do things which I enjoy doing.” It could be physical activity, it could be artistic pursuits, whatever, and that really takes time. It’s not something which you can just say, “Hey, I want to live well,” you have to sit down and think about it and work out what works for you.
There is no one secret formula, different things will work for different people. In recent years it’s been lots of physical activities. On weekends I might go for a long bike-ride or I might go kayaking for a while. But for other people it will be different things. Being upright and honest with yourself about how you’re feeling, how you’re managing and what you need to do to make things work for you, I think that’s key, and I guess along with that having adequate sleep. Yeah, especially when it comes to dealing with patients, you don’t want to be there when you’re half asleep—that’s for me anyway.
: I think as a junior physician there’s always a risk that you’ll take too much work on. You don’t want to let people down by saying no, so there’s always a natural inclination to say yes. I think learning skills of delegation are important. There’s different periods of life where the pendulum may swing various ways and I’m just at a point in time in my life where it’s more important I suppose for me to be spending more quality time with my family. But as children grow up, then the pendulum may swing the other way down the track.
: For doctors it is totally unrealistic to suggest that you can get out of the hospital for a lunch hour, or that you can leave work on time. I think it is realistic to make sure you always eat lunch. In terms of leaving work on time, over the years I’ve found there’s usually one day a week that I can say, “I am definitely going to leave at four pm or five pm or whatever on those days,” because I know I don’t have any acute patient interaction that evening. It’s also very good to make an arrangement with somebody else, so be it meeting up with a friend in a coffee shop or meeting up with someone for drinks after work, or just the fact that you have to get home to make dinner is a very good incentive for leaving on time. If you don’t block out time in your diary to do these things they won’t happen.
: I think some people are probably very good at looking after themselves, and those are the doctors that eat breakfast in the morning and do all the right things, and they have an hour break and they take it, and all the rest of it. I think intensive care is not usually a speciality where doctors are very good at looking after themselves. Theirs is a speciality that it’s usually taken up by people who are adrenaline-driven and they just do go go go, and I must say that I’m probably one of those people—I’m guilty of that as well.
I think my hours actually are worse since I’ve become a consultant, so I would say that I looked after myself better when I was a trainee, and I probably work longer hours now. Sometimes it’s out of your hands when something is happening for 12 hours straight and you don’t have time to sit down to eat or drink. I think it is tough and you need to make space. You know, I had a period in my life where I had burn-out and you have to be really careful to try and get out of that.
: Burn-out is an important issue in the professions these days, as people are coming to recognise it more and more. We used to think it was definitely the domain of the older professional but now in burn-out surveys we’ve found particularly younger women are showing the most signs of burn-out, and many workplaces are now discussing it and looking to ways of managing it. There is some evidence around this now and occupational psychologists know a lot about this and can give information around it.
If you start to suspect that you’re experiencing burn-out, you’re feeling less engaged with your work, it’s just seen as a job and that you’re not interested in it anymore, you’re stressed at home, you’re stressed at work, and there isn’t another good explanation, then the best things you can do are to seek supervision and mentorship around this. There might be ways you can change things at work that will make life easier. Be honest with your clinical leader, go and talk to the Chief Medical Officer, talk to someone who you know would have some empathy with the situation; perhaps there are colleagues around who have been through a similar process. You can use your non-clinical supervisor for that, but the College of Physicians also has a counselling support and you can phone their 24-hour line, and in other countries there are similar supports for people.
There are also supports from the hospital and organisations; most places will have an occupational health physician and also a counselling service for all of their employees. It’s probable that you’ll need to talk to a number of different people before you can find a way through burn-out and before you can even know that it is burn-out that you’re experiencing. It might be that something else is going on and the reason you’re tired and stressed is because actually you’re hypothyroid or iron deficient, and so, getting those basic things checked out first and taking their advice is also vital.
I would say to people, the key things for keeping engaged at work are maintaining some ability to walk away but also maintaining your curiosity and your interest in your job rather than just it being a thing that you do to pay the rent or the mortgage. Non-clinical supervision is a vital part of engaging with burn-out. If you talk to your colleagues there’s often a sense of, “This is just the way it has to be,” whereas when you talk to a non-clinical supervisor who doesn’t work in that area they look on in horror at some of the work you’re doing and can provide good ideas or help you explore your own ideas for how to better engage and get more out of your life and be able to say no to the commitments that are going on at work.
: I think not a lot of people like to talk about burn-out, because we’re all “really tough and strong and we can do everything,” but I think we now find more and more that this is not the case. Because people think, “If I admit this what’s going to happen? What am I going to do about it?” You know, at the very least I think everybody should have a GP they can trust and they should be able to go to and discuss things with.
: I mean, I’ll fess up and say that I haven’t had a GP, or I haven’t seen a GP, since I was in medical school—greater than 10 years ago, but that’s not uncommon. And the only reason I saw a GP was to get some paperwork filled out for income protection. This allowed us to have a conversation about me neglecting my own health…so that’s now been corrected.
: Having your own GP is crucial to any doctor partly because, regardless of what specialty you do, they know stuff you don’t. It never ceases to surprise me because I’ve always made my own diagnosis before I go and see my GP and quite often I’m wrong. So, it’s very useful. And I go into my GP with, “This is what I think is happening,” but if they tell me that actually they think it’s something different I always listen to their opinion, respect their opinion and do what they tell me to do.
There are a number of stages of life in a medical career that are the most challenging, but having done all of them becoming a consultant is both the most challenging and the most rewarding. It is definitely worth it. I’m really pleased I went through the years of training and some of the struggles that that involved. I love my job. I really enjoy all the things that being a consultant allows me to do: to work in a team, to have other people’s opinions around me all the time but also to be able to be part of the leadership team and to call the shots on patients when I feel I need to. I love working in a long-term relationship with many patients, rather than just seeing them for six months and I love being in a long-term relationship with my organisation as well and actually looking to the future as to how we can be the best possible general medicine department.
: It is a good feeling. You’ve finally taken your place as a consultant physician and that’s extremely rewarding.
: I love my job. And I’m not being sarcastic when I say that. I’ve got a fascinating job in both my inpatient and outpatient experiences and I live 10 minutes from the hospital and I often get to drop my kids off at school on the way to work. It’s a great place to be.
Thanks to Ben Vogler, Marion Leighton, Lawrence Ong, and Martina Moorkamp for sharing their stories on this episode of Pomegranate Health. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians.
The College’s guide for new consultants can be found through our website at racp.edu.au/pomcast, along with some other interesting reading. You’ll also find information on the RACP Support Program, a 24-7 counselling service available for all members to discuss workplace and personal stress. In Australia you can call 1300 687 327, and in New Zealand it’s 0800 666 367.
If you want to hear another great podcast, listeners recommend Emergency Medicine Cases. This is one of Canada’s most listened-to medical podcasts and it also has a blog that is always up-to-date. Anton Helman hosts round-table discussion of case studies and journal discussion with expert researchers and clinicians. Check it out at emcases.com.
Today’s episode was produced by Zacha Rosen with research assistance from Beverly Bucalon. Please get in touch with us if you have suggestions for the show, via firstname.lastname@example.org.
I’m Mic Cavazzini. Thanks for listening.