My life as an ST-LAT in Acute Medicine

Where are you in your training right now?

ST-LAT (locum appointment training) Acute Medicine – that makes me ST4.

I didn’t pass my PACES by end of core training, so I completed my first registrar year as a LAT. I realised I didn’t feel ready to jump on the conveyor belt to becoming a consultant – and kept on working as a LAT!

What region are you working in?

The northeast of Scotland.

What stage did you decide on your specialty & what other specialties were you considering?

I loved my acute medicine attachment when I was a 4th year medical student and haven’t really stopped thinking about it since. I have briefly considered gynae-oncology (after doing my first FY1 job in Gynaecology, but got put off by needing to do obstetrics as well – plus I never had the best hand-eye coordination to be a surgeon!) and Diabetes & Endocrine.

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What brought you to your decision?

I have done a CMT1 job in Acute Medicine, and I loved being there. There was no turning back, really! I knew I had to stay in the region due to my partner’s work commitments (oil & gas) but that didn’t really matter – if anything, it made the decision easier.

The department was run by a consultant with a vision for efficient service provision and an insane drive for quality improvement. My team was incredibly welcoming and friendly at all levels, both nursing and medical.

I love the acuity of the unit – the occasional pressure of decision making. The fact that when I assess someone very sick from the community it’s a total team effort. I’ve watched a team of 15 people – both medical and nursing – descend onto a very unwell patient to cannulate, run ECGs, run fluids – and all I have to do is take a story, examine and make a plan as we go along. I love the fact that I need to keep a very open mind when people come through the door. Things aren’t always what they seem at the outset.

Yes, it can sometimes be a stream of the same, especially come winter time (LRTI, CAP, LRTI, CAP*) – but then an amazing case or a very unwell patient comes along, and they improve under our care. Or a thankful family – and that makes up for all the worse times.

How have you found the exams so far? How did you revise for them?

MRCP wasn’t fun. I used combination of books and online question banks for parts 1 and 2, and clinical practice, questions, and videos for PACES.

How is your day job split up – when you’re not on-call?

Acute med works a little differently here – we have three areas we cover:

• Acute initial medical assessment – your typical unselected acute medical take with GP referrals only (we don’t take ED referrals where I work). It can be nuts, especially in winter, but it’s very rewarding. We ‘senior review’ patient already clerked by juniors, tidy up any investigations and dispatch them to appropriate specialty ward. We resuscitate any of the more unwell ones. It’s a well-supported environment with at least one consultant on the floor at any given time between 9am and 10pm.
• Ambulatory emergency care – here, we see pretty much everyone that needs to be seen – but they’re normally well enough to go home. It can feel like juggling over hot coals, as you can have five or seven patients on the go. But it is very rewarding – and consultants are around at all times for advice.
• Medical short stay ward – like your general medicine ward, but with an estimated admission length of less than 72 hours. We see a lot of chest pains, pneumonia, asthma, COPD, cellulitis. We do daily ward rounds, and appointments in the afternoon.

We also give advice to GPs in the community over the phone.

Additionally, we contribute to the Hospital@Night – we have a two registrar system – one person manages the acute admissions unit (we can get up to 25 admissions overnight!), the other firefights around the hospital – we try to help each other out as we go through the night.

We don’t routinely review unwell medical patients in other parts of the hospital (each ward has their own registrar) or medically unwell surgical patients, unless they phone overnight.

What aspects of being a Medical Registrar have you enjoyed the most? What has been hard?

I found the step up from CMT2 to ST3 quite challenging – suddenly I was in charge of the ward round! I think I put too much pressure onto myself. I forgot that the consultants remembered me being a CMT2 the previous week.

I love nights and being part of Hospital@Night, and looking after my juniors. I’m not a fan of surgeons taking my word as gospel, though!

What’s the best thing about being a Medical Registrar?

I really don’t know. Not having to do MedRec? I really like my job in general – I’m lucky to work in a supportive environment.

And the worst?

“Everything is medicine until proven otherwise” seems to be the state of mind amongst some surgical colleagues. Even if it’s clearly cholecystitis or a broken leg, which then somehow becomes my problem until I can demonstrate an inflamed gallbladder or a hip fracture.

I also hate getting involved in bed management situations – they’re never-ending, and it feels  like it’s beyond my paygrade. My hospital has a dedicated bed management team – who end up asking me questions about bed management!). I loathe being forced to make said decisions at 4am.

Could you share with us your most challenging moment as a Med Reg?

There have been some challenging decisions around palliation, especially in moribund young but frail patients with no agreed escalation plan.

What advice would you have for managing all the medical referrals?

Divide and conquer; trust your juniors. I review all patients when the juniors explicitly say, ‘I want you to see this person’ – otherwise I ask them twice whether they want me to come up and see someone – I feel that this is relatively fair balance between giving them autonomy and being safe in our practice.

What do you think are the most critical personality traits that a doctor should possess for a career in medicine?

Resilience and good sense of humour.

What needs to be done to make medical training fit for purpose?

A concern of many trainees applying for medical training is the work-life balance; how do you cope wit constant nights and weekends?

As of this year I have applied for LTFT (80%) training purely due to work-life balance needs. I’ve yet to see what impact it has, but I’m hoping it’ll make a difference. I would encourage everyone to consider it if they can afford it.

With medicine and training becoming increasingly specialised – is the General Physician dead?

Absolutely not. Growing emphasis on acute medicine as a specialty within own right is the perfect example. All is well with organologists, but you still need someone who can pull it all together – who is going to look after the not-so-elderly, but frail with a bit of AKI, heart failure and pneumonia? General medicine should be resurrected and endorsed. It is a skill.

What’s your number one piece of advice to junior doctors who are considering applying for medical training?

Don’t rush it if you don’t feel ready – there’s nothing wrong with a LAT year or two