Hi everyone, my name is Alex and I am an acute medicine trainee in East of England. I am ST7 and in my final year of training now. It feels like quite some journey with 11 years since graduation taking in 10 hospitals (7 in training).
My specialty interest for Acute Medicine is Leadership and Management and I am just completing a chief registrar year (‘24-‘25), for which I have gone 40% non-clinical and will therefore CCT 40% of a year later than previously planned- one of the requirements of the programme, it is important to note.
My year as chief reg has been very interesting and I have tried to get the very best from it. I think that it has worked really well alongside acute medicine training and has given me the opportunity to get involved in service change and improvement, looking particularly closely at the medical take.
I started my year by getting a good understanding of what was currently going on in my trust in terms of quality improvement. I looked at projects going on at a departmental and trust level and was surprised to hear of several extremely good pieces of work that I had no idea were happening- one of the advantages of joining a programme which allows some oversight into hospital processes, including invitations to departmental, divisional and trust meetings.
Having looked at ‘the lay of the land’, I mapped out a plan on how to increase the QI projects going on in my hospital. I did this by preparing an online seminar series which I taught to the East of England deanery, covering the importance of QI and the advantages of it to applications and training portfolios. We also looked at how to set up a QI project and some of the fundamentals of QI including the PDSA cycle, driver diagrams, and run/SPC charts. Finally, we covered how to collect data that can be analysed, and potential conferences to present poster projects at, including looking at the advantages of verbal presentation practice.
Having stirred up interest in QI, I then built several teams around the projects I wanted to focus on. As an Acute Medicine trainee, I felt the best areas to add to were based on improvement of the medical take, which is often difficult to optimise owing to variable demands on the service through the year. Last winter was a particularly busy one and it became clear that a solution looking at this would be most valuable. So, I set to work.
It is really important with QI, not to re-invent the wheel. I was very lucky that at my trust there was already a GIM committee looking at handover, post graduate medical education and satisfaction of trainees on the take. It seemed best to integrate with this team and try to find common objectives, since they had already established good communications channels with decision makers, and good meeting practices.
My main area of interest for the year became the productivity of the medical take. I recently presented my work as chief reg at both the RCP, and my local trust and ran an exercise where I asked everyone to stand up, then to sit down if the answer to any of the following questions was ‘yes’.
– Do you find the medical take chaotic or disorganised
– Have you ever been through an entire take shift without having lunch?
– Have you ever wondered where your work colleagues were whilst on take?
– Have you ever wondered what your performance is like on take and how it bench marks against colleagues?
In both presentations, I asked the first question and everyone sat down. This, for me, highlights how the medical take is seen as disorganised across the UK. To a certain extent, I believe that this is because of the nature of the work with unplanned emergency care, colliding with a GP workforce who has drawn significant new boundaries on appointment times post covid, meaning that a whole swathe of patients who were previously managed in the community, now come to secondary care. What are we to do in this context? Just turn them away? Or draw our boundaries also leaving them queuing down the street? The alternative is to try to think of another way of working in order to see these patients more effectively, using the same current resources we have. I believe that the third option in the current healthcare climate, is all we have. So, my project this year was titled;
A little team work makes the dream work: Optimising medical take using the strength of small teams in line with RCP guidance.
During the project I explored carving down the medical take into manageable blocks, by location and placing a small modular team in each block with a registrar in each area to enable good accountability and escalation of decisions within the teams.
Now this may seem like an obvious solution. What do we do when a task is overwhelming? We carve it down into blocks and go after each in turn. So how is this concept any different? Well, the truth is, it isn’t. The only difference is that rather than one person going after each task consecutively, the whole take team is working simultaneously in these areas to optimise the accountability for the area, supporting juniors in escalation of decision making so that no individual is left making a decision which the grade above them could make more quickly, for too long.
It’s a simple concept, but it works. We have shown, on a 6-week trial in Feb and March this year, that we can increase the number of patients seen per doctor by an average of two (across all grades) in a 10 hour shift. With 11 doctors on take at peak time, this is up to 22 extra reviews that can take place. If used well, that is a significant proportion of the medical take (70-100 patients in my trust) which can be seen during day hours, reducing
wait times, increasing patient safety and satisfaction, and reducing the strain on night teams, where staffing is less.
I have learned a lot from my journey as chief registrar. I have combined my QI work (something I have always gained a lot from) with service improvement and also taken the opportunity to work through the RCP check list to meet as many hospital leaders as possible, including head of department, clinical directors, head of division, medical directors and the CEO. I have explored the RCP regional leads and the leads for the GMC and patient safety as well as the guardian of safeguarding at work. All of this has combined to give me a unique perspective of how the hospital works and the complexities of the system. I believe that this is the purpose of the chief reg programme.
The above, combined with 10 days at the RCP through the year learning about QI methodology and personality types (including methods on how to achieve positive change), culminated in the opportunity to present my work at the RCP, which I gratefully accepted.
The year has been extremely useful as I navigate a journey through clinical leadership. I highly recommend it and if you can resign yourself to an increase in training time of 40% of a year, you will get a huge amount of the experience. I think my most important take homes are:
-Don’t re-invent the wheel with QI. See what’s going on and how you can add to it
-Be prepared for how complex the hospital system is, with conflicting interests and varying ideas on the best way of making improvements (you will need to develop ninja skills to make positive change- something I am still working on, as some of my peers will attest to!)
-Jump in, join that meeting even though you don’t know what for or why- something positive will come of it
-Take every opportunity to present your work- communication is key in generating positive change and improvement
-When your data (and you should gather some. Nothing else speaks more than having robust proof), proves an improvement, your project is about halfway there. The next 50% of your effort will be in implementing a lasting change into the culture. The complexities of this should not be underestimated.
-Meetings to understand peoples work and processes are useful. Meetings to communicate current situations are useful. Meetings where action points are developed, but no one owns them or carries them out, are less useful.
I believe that the chief registrar programme fits very well with acute medicine as we, as frontline doctors, are best placed to ensure patients are efficiently and effectively seen in hospital or safely discharged. It is crucial we find solutions to the current strain on the hospital and the QI methodology for change and improvement needs to be constantly developed and honed so that we can continue to improve services in the face of constantly evolving pressures.
I hope that you find the programme and opportunity as useful to your development as I have!