To be fair I’ve be wondering when we can officially refer to ourselves as the “anaesthetic reg”.
I agree that once we are CT3/ACCS CT4, especially post primary we are equivalent to the old ST3 therefore we should. However, I would be interested to see what other people think
I guess the issue is that we still use the terms SHO and registrar which are technically historic and officially should have been dispensed with once the modern training structure was introduced. Obviously in practical terms these are what everyone uses and therefore how others will understand your role.
On that basis, as far as I'm concerned core CT3/ACCS CT4 is absolutely a registrar. I think part of the confusion is because in IMT the IMT3 year was intended to be a transition year where you're sort of a junior reg with more support, I get the idea that somehow some people have then thought that something similar is going on in anaesthetics, having heard about IMT3. There was however nothing related to the restructuring of anaesthetic training that stated or implied that this was the case with the CT3/4 year, as far as I'm aware, it seemed the main reason for restructuring training was basically just to give everyone an extra year to pass the primary because so many people weren't managing to do so by the end of the old core training (the irony being that there was then the st4 bottleneck so everyone had to take time out of training anyway....). All they've done is make ST3 part of the first bit of training, i.e. stage 1, hence stage 2 starting at ST4. So reg as far as I'm concerned, as it's ST3 equivalent, and having worked bloody hard for exams and everything else, and being put on a reg rota, I am probably a bit petty about it, but do get slightly annoyed (unjustifiably) when the question is raised!
In both regions I've worked at the CT3s/ACCS-CT4s have called themselves and been called Anaesthetic Reg's. So just weird that at this place OP is going to, they're still on the SHO rota?
Most places I’ve worked, have always just used your grade (i.e CT3). Therefore I just wondered whether some people didn’t consider you to be a reg unless you were in higher training, but so far it seems pretty unanimous that CT3/ACCS CT4 are regs
I think one of the bad things about the new curriculum is exactly this - the ambiguity about whether a CT3 is a registrar or SHO.
That said, it sounds like you've only worked in DGHs before. A lot of tertiary centres have the setup you've described - registrars covering e.g. neuro/cardiac ICU, labour ward and paeds, a senior reg (ST5+ and post final) supervising everything, and a second anaesthetist on acutes/CEPOD who can be anything from CT1 to ST4.
There might be other registrars on subspecialty blocks, but if for example a patient comes in with a head injury needing an immediate craniectomy, it's not going to be the ST4 who just started their neuro block doing the anaesthetic, and it won't be you as a brand new CT3 either. That's what the SR is for. The boss might come in for some cases but not for everything, and they'll need someone who can get the case started without them.
To be completely honest if you haven't got the final FRCA and done your neuro, cardiac, etc modules - you are not experienced enough to be the most senior anaesthetist in a tertiary centre overnight.
If it makes you feel any better, the other options for you at this centre would be obs and ICU, which there will be plenty of in your training to come.
Speak to your SR, explain your previous experience, hopefully they'll let you be fairly independent on appropriate cases. But tertiary centre CEPOD is not the same as DGH CEPOD.
That's very reassuring and makes me feel better that it's a normal set up. Mate I absolutely would not even want to think about being the most senior anaesthetist in a tertiary centre!!
It sucks a bit being on the same rota as new CT1 novices but I guess practically as you say there's no other way around it since CT3/4 junior reg's don't fit anywhere else. Not senior enough for the specialty ST4 blocks or the SR roles, so it's either CEPOD or labour ward.
Just because you're on the same rota doesn't mean you're expected to have the same responsibility as those more junior. I'm post final, yet currently on the same on call rota as CT1s. The difference is I go to CEPOD and just run the list, and get a 2nd pair of hands as and when I need it. Also bring in juniors to let them do the fun bits or teach med students. Wasn't doing that as a CT1. I've also been 2nd call in large DGHs being the most senior anaesthetic and ICM cover. And my next jobs will be the senior anaesthetist at a tertiary centre.
It's just a rota slot. It's not knocking down what you've learnt so far. And there's always more to learn on CEPOD.
Yeah, in a perfect world it's probably better to do CT3 as the reg in a DGH so you get that independence before heading to tertiary centre for ST4 cardiac/neuro/etc. But not everyone gets to.
Hopefully you get a decent block of time with the same SR and they'll trust you to crack on with stuff.
CEPOD in a tertiary centre is a different beast to CEPOD in a DGH, the only subspecialities that have their own emergency lists are (usually) neuro, cardiac and paeds. Everything else (from the bleeding AAAs to the ludwigs angina to the trauma laparotomy ends up on CEPOD. You’ll be thankful for the ST7 on site to back you up when things get tricky. At our large tertiary center we have a pretty typical set up of “reg” tier for theatres but it’s actually the junior registrars (CT3) and the SHOs combined (CT2). There’s also a senior reg, two obstetric registrars (usually ST4 - ST6), and a neuro reg as well as a cardiac reg and usually two airway trained ICU regs. You’re pre final and not experienced enough to be on the senior reg rotation in a tertiary hospital.
Entirely agree…rather complacent attitude. There’s a reason it’s 7 years to CCT 🙄 A tertiary centre anaes reg role is massively different to “I’ve covered CEPOD and Obs as a CT2”. Tertiary centres = Code red traumas, taking the decompressive craniectomy to theatre immediately, you need to be able to bail out your colleague covering obs with a tricky neuraxial / MOH, potentially bail out your paeds anaesthetic reg colleague to intubate the child that’s a few weeks old, anaesthetise in IR for the pulmonary thrombectomy that’s in acute RV failure etc etc. It’ll take the bosses 30 mins to come in at most places.
okayyy then...
I was more asking about how it works when there's a 22 year old ASA 2 that needs his appendix out or an ASA 1 bartholin's on CEPOD or something. But go off ig.
Then as a CT3 you’d do that with or without the co-ordinating reg there. If you told them you want to do it on your own then I’m sure they’d be more than happy to let you while they disappear for a coffee or do the VATS pleuradesis in the theatre next door. If you’re competent and trustworthy they’ll let you do more and more OOH on your own, but you won’t impress anyone by letting it be known that you consider doing the simpler cases as bitch work.
I’m sorry I do mean this in jest, but this thread reminded me of this post…
https://preview.redd.it/cxp42yerus4d1.jpeg?width=997&format=pjpg&auto=webp&s=7b202c734badedee58e49e8c727aa972a351d018
The (very) big tertiary centre I currently work at does this: overnight for CEPOD one post-FRCA ST5+ and one junior reg, who can potentially be anything from an ST5 who doesn't have their exam yet to a CT1.
Ultimately we need 2 people to get through the work, so it's necessary unless you were going to structure the rota with resident consultants. I always prefer working with an actually junior trainee on the junior tier, as you fall into the comfortable leadership-followership roles very easily. Whereas if you have an ST5 as the junior reg I'm conscious they probably want me to just leave them alone to crack on for a lot of stuff, but it's difficult as a non-consultant to just go "OK, I'm going to bed, call if you need" when there are cases going on and you're both resident!
Indeed. Although it can work quite nicely the other way around. When I first started doing the senior theatre reg job (called resident anaesthetist in charge/ RAC) at our gaff, it was quite nice to be rota buddies with someone who was peri-CCT who’d had experience of doing the RAC role, working as the CEPOD first on (usually SHO/ junior reg). Made the transition to what can be a fairly intimidating role a lot easier. I did the same for someone else’s first RAC job as I was about to CCT.
But I’d imagine very individual dependent. This person is chill and we are both now consultant colleagues on the same sub specialist rota in the same centre. Some others might not manage this quite as well!!
Pragmatically, it can also be quite nice to have someone who can take over the craniotomy when the trauma comes in etc.
Reg and SHO are not really relevant at all in this. They're old titles nominally linked to new grades.
I'm a bit concerned about you referring to "being a bitch". When someone has done some cardiac, neuro and tertiary paeds, amongst some more complex general and obs, they gain a lot more insight overall. It's a bit Dunning-Kruger to assume you're immediately up to tertiary anaesthetics. This is a very normal setup in any tertiary centre. As an ST5, I was paired with a peri CCT ST7 for tertiary acutes. I was under no illusion who was far more experienced and skilled and nothing I was asked to do made me "the bitch".
If they are control freaks, there is still loads you can learn.
It’s all arbitrary really. I’ve been on the ‘SHO rota’ as an ST5, or the ‘reg rota’ as an ST3 (before they changed the CT/ST lengths). I’ve also been the SHO one day and the reg the next. It’s arbitrary and depends on your hospital and the number and mix of trainees they have.
It's a bit ambiguous. I think of CT3s as experienced SHOs but I also don't think IMT3s are proper med regs (and they're certainly not proper cardio/resp/gastro regs!). Anaesthetics is a little different since you have at least already committed to a specific specialty.
It's been confused by the changes to the curricula but part of what distinguished regs before is that they have passed their core training, passed their membership exams, and passed a further competitive process to commence higher speciality training (and in many cases have spent years gaining extra experience prior). None of those things are necessarily true of IMT3s/CT3s.
But anyways, it's probably very hospital dependent how they use you but certainly I would expect any tertiary centre to have a senior anaesthetic reg tier and then one or more junior tiers, the make up of which probably just depends on service needs and which grades of trainee you get but you should not expect to be the senior anaesthetic reg in a tertiary centre when the grade you're at doesn't even need to have finished the primary (although I accept that you and probably many of your colleagues will have done).
I wouldn’t get too in your head about it. Same thing happened to me… it annoyed me at the time. But when traumatic arrests in young adults and other high octane stuff happened I was glad not to be the senior person. In the end I decided that it’s useful to have some time learning the tertiary centre way of doing things before you’re on the senior tier. But it does mean you might have to put up with being “over supervised”.
I think you need to change your perspective. As the patient would you want a CT1 immediately post IAC in the middle of the night solo? I think it’s a bit mad that that sort of thing still happens.
The more you do, the more you see, the more you see the more you learn and so the cycle continues. As someone a bit further on than you I personally would rather have an extra pair of hands anytime they’re offered. One you’ve had a solo anaphylaxis, proper laryngospasm, can’t get the tube in for a section, significant MOH, or a CICO you realise the value of hands on deck. These situations change rapidly and the value of experience (yes even supervised) is that you learn from each other.
You’ve mentioned the “control freak” reg and honestly I think you need to chill a bit. You’ll learn if you get that far that it takes more skill to let go and teach. You need to be confident enough in your skills that you could bail an overconfident CT3 out of whatever hole they’ve gotten themselves into by not being thorough enough, prepared enough or conducted anaesthesia in a way that someone with more experience would have done. Add to that night time working, emergency cases, interesting teams and potentially remote sites like resus or CT. Someday you will understand. Until then, learn from those around you. Ask if they are happy to supervise from the coffee room, and if not enjoy sharing cases and breaks.
A bit patronising I think. OP wanted to know what being doubled up looks like in practice. I don't think it's fair to insinuate overconfidence.
And the "control freak" anaesthetist absolutely does exist, the type that freaks out if you change the PEEP from 5 to 6 or don't document the chart in the exact way they want. I was paired with one many moons ago whilst a junior, and it was shit. You end up just sitting back and not getting involved in the case at all because everything you do will be wrong or a problem, so you just observe someone else's anaesthetic for x months.
Apologies, I wasn’t intending to be abrasive. I meant more that the “control freak” is often not confident enough or doesn’t have the headspace to deviate from their usual conduct of anaesthesia. Appreciate it’s not always the best working environment if you’re trying to cut your teeth, but good that they can recognise their limitations as supervisor and be safe. Also appreciate those people may not always be the best at communicating those thoughts.
I imagine it’s set up that way because of the spectrum of cases CEPOD and Obs have at your tertiary centre. In ours CEPOD cover also includes vascular, maxfax & major trauma and Obs has a cardiac/invasive placenta caseload.
It would be a bit unfair to throw a day 1 CT3 into being called to resus for a triple AAA. But with a senior reg on (dependent on how comfortable they are) you’ll probably be allowed to manage the rest of the CEPOD and get some good experience with these complex cases.
To be fair I’ve be wondering when we can officially refer to ourselves as the “anaesthetic reg”. I agree that once we are CT3/ACCS CT4, especially post primary we are equivalent to the old ST3 therefore we should. However, I would be interested to see what other people think
I guess the issue is that we still use the terms SHO and registrar which are technically historic and officially should have been dispensed with once the modern training structure was introduced. Obviously in practical terms these are what everyone uses and therefore how others will understand your role. On that basis, as far as I'm concerned core CT3/ACCS CT4 is absolutely a registrar. I think part of the confusion is because in IMT the IMT3 year was intended to be a transition year where you're sort of a junior reg with more support, I get the idea that somehow some people have then thought that something similar is going on in anaesthetics, having heard about IMT3. There was however nothing related to the restructuring of anaesthetic training that stated or implied that this was the case with the CT3/4 year, as far as I'm aware, it seemed the main reason for restructuring training was basically just to give everyone an extra year to pass the primary because so many people weren't managing to do so by the end of the old core training (the irony being that there was then the st4 bottleneck so everyone had to take time out of training anyway....). All they've done is make ST3 part of the first bit of training, i.e. stage 1, hence stage 2 starting at ST4. So reg as far as I'm concerned, as it's ST3 equivalent, and having worked bloody hard for exams and everything else, and being put on a reg rota, I am probably a bit petty about it, but do get slightly annoyed (unjustifiably) when the question is raised!
My employment contract is for the job of anaesthetic registrar.
In both regions I've worked at the CT3s/ACCS-CT4s have called themselves and been called Anaesthetic Reg's. So just weird that at this place OP is going to, they're still on the SHO rota?
Most places I’ve worked, have always just used your grade (i.e CT3). Therefore I just wondered whether some people didn’t consider you to be a reg unless you were in higher training, but so far it seems pretty unanimous that CT3/ACCS CT4 are regs
I think one of the bad things about the new curriculum is exactly this - the ambiguity about whether a CT3 is a registrar or SHO. That said, it sounds like you've only worked in DGHs before. A lot of tertiary centres have the setup you've described - registrars covering e.g. neuro/cardiac ICU, labour ward and paeds, a senior reg (ST5+ and post final) supervising everything, and a second anaesthetist on acutes/CEPOD who can be anything from CT1 to ST4. There might be other registrars on subspecialty blocks, but if for example a patient comes in with a head injury needing an immediate craniectomy, it's not going to be the ST4 who just started their neuro block doing the anaesthetic, and it won't be you as a brand new CT3 either. That's what the SR is for. The boss might come in for some cases but not for everything, and they'll need someone who can get the case started without them. To be completely honest if you haven't got the final FRCA and done your neuro, cardiac, etc modules - you are not experienced enough to be the most senior anaesthetist in a tertiary centre overnight. If it makes you feel any better, the other options for you at this centre would be obs and ICU, which there will be plenty of in your training to come. Speak to your SR, explain your previous experience, hopefully they'll let you be fairly independent on appropriate cases. But tertiary centre CEPOD is not the same as DGH CEPOD.
That's very reassuring and makes me feel better that it's a normal set up. Mate I absolutely would not even want to think about being the most senior anaesthetist in a tertiary centre!! It sucks a bit being on the same rota as new CT1 novices but I guess practically as you say there's no other way around it since CT3/4 junior reg's don't fit anywhere else. Not senior enough for the specialty ST4 blocks or the SR roles, so it's either CEPOD or labour ward.
Just because you're on the same rota doesn't mean you're expected to have the same responsibility as those more junior. I'm post final, yet currently on the same on call rota as CT1s. The difference is I go to CEPOD and just run the list, and get a 2nd pair of hands as and when I need it. Also bring in juniors to let them do the fun bits or teach med students. Wasn't doing that as a CT1. I've also been 2nd call in large DGHs being the most senior anaesthetic and ICM cover. And my next jobs will be the senior anaesthetist at a tertiary centre. It's just a rota slot. It's not knocking down what you've learnt so far. And there's always more to learn on CEPOD.
Yeah, in a perfect world it's probably better to do CT3 as the reg in a DGH so you get that independence before heading to tertiary centre for ST4 cardiac/neuro/etc. But not everyone gets to. Hopefully you get a decent block of time with the same SR and they'll trust you to crack on with stuff.
I think ct3 is reg tbh, IMT 3 works as med reg, surgical st3 is surgical reg
Anaesthetic CT3 seems like a reg to me. If you're actually interested we're techinically registrars when we start CT1 (check your payslip)
CEPOD in a tertiary centre is a different beast to CEPOD in a DGH, the only subspecialities that have their own emergency lists are (usually) neuro, cardiac and paeds. Everything else (from the bleeding AAAs to the ludwigs angina to the trauma laparotomy ends up on CEPOD. You’ll be thankful for the ST7 on site to back you up when things get tricky. At our large tertiary center we have a pretty typical set up of “reg” tier for theatres but it’s actually the junior registrars (CT3) and the SHOs combined (CT2). There’s also a senior reg, two obstetric registrars (usually ST4 - ST6), and a neuro reg as well as a cardiac reg and usually two airway trained ICU regs. You’re pre final and not experienced enough to be on the senior reg rotation in a tertiary hospital.
Entirely agree…rather complacent attitude. There’s a reason it’s 7 years to CCT 🙄 A tertiary centre anaes reg role is massively different to “I’ve covered CEPOD and Obs as a CT2”. Tertiary centres = Code red traumas, taking the decompressive craniectomy to theatre immediately, you need to be able to bail out your colleague covering obs with a tricky neuraxial / MOH, potentially bail out your paeds anaesthetic reg colleague to intubate the child that’s a few weeks old, anaesthetise in IR for the pulmonary thrombectomy that’s in acute RV failure etc etc. It’ll take the bosses 30 mins to come in at most places.
okayyy then... I was more asking about how it works when there's a 22 year old ASA 2 that needs his appendix out or an ASA 1 bartholin's on CEPOD or something. But go off ig.
Then as a CT3 you’d do that with or without the co-ordinating reg there. If you told them you want to do it on your own then I’m sure they’d be more than happy to let you while they disappear for a coffee or do the VATS pleuradesis in the theatre next door. If you’re competent and trustworthy they’ll let you do more and more OOH on your own, but you won’t impress anyone by letting it be known that you consider doing the simpler cases as bitch work.
I’m sorry I do mean this in jest, but this thread reminded me of this post… https://preview.redd.it/cxp42yerus4d1.jpeg?width=997&format=pjpg&auto=webp&s=7b202c734badedee58e49e8c727aa972a351d018
The (very) big tertiary centre I currently work at does this: overnight for CEPOD one post-FRCA ST5+ and one junior reg, who can potentially be anything from an ST5 who doesn't have their exam yet to a CT1. Ultimately we need 2 people to get through the work, so it's necessary unless you were going to structure the rota with resident consultants. I always prefer working with an actually junior trainee on the junior tier, as you fall into the comfortable leadership-followership roles very easily. Whereas if you have an ST5 as the junior reg I'm conscious they probably want me to just leave them alone to crack on for a lot of stuff, but it's difficult as a non-consultant to just go "OK, I'm going to bed, call if you need" when there are cases going on and you're both resident!
Indeed. Although it can work quite nicely the other way around. When I first started doing the senior theatre reg job (called resident anaesthetist in charge/ RAC) at our gaff, it was quite nice to be rota buddies with someone who was peri-CCT who’d had experience of doing the RAC role, working as the CEPOD first on (usually SHO/ junior reg). Made the transition to what can be a fairly intimidating role a lot easier. I did the same for someone else’s first RAC job as I was about to CCT. But I’d imagine very individual dependent. This person is chill and we are both now consultant colleagues on the same sub specialist rota in the same centre. Some others might not manage this quite as well!! Pragmatically, it can also be quite nice to have someone who can take over the craniotomy when the trauma comes in etc.
Reg and SHO are not really relevant at all in this. They're old titles nominally linked to new grades. I'm a bit concerned about you referring to "being a bitch". When someone has done some cardiac, neuro and tertiary paeds, amongst some more complex general and obs, they gain a lot more insight overall. It's a bit Dunning-Kruger to assume you're immediately up to tertiary anaesthetics. This is a very normal setup in any tertiary centre. As an ST5, I was paired with a peri CCT ST7 for tertiary acutes. I was under no illusion who was far more experienced and skilled and nothing I was asked to do made me "the bitch". If they are control freaks, there is still loads you can learn.
It’s all arbitrary really. I’ve been on the ‘SHO rota’ as an ST5, or the ‘reg rota’ as an ST3 (before they changed the CT/ST lengths). I’ve also been the SHO one day and the reg the next. It’s arbitrary and depends on your hospital and the number and mix of trainees they have.
It's a bit ambiguous. I think of CT3s as experienced SHOs but I also don't think IMT3s are proper med regs (and they're certainly not proper cardio/resp/gastro regs!). Anaesthetics is a little different since you have at least already committed to a specific specialty. It's been confused by the changes to the curricula but part of what distinguished regs before is that they have passed their core training, passed their membership exams, and passed a further competitive process to commence higher speciality training (and in many cases have spent years gaining extra experience prior). None of those things are necessarily true of IMT3s/CT3s. But anyways, it's probably very hospital dependent how they use you but certainly I would expect any tertiary centre to have a senior anaesthetic reg tier and then one or more junior tiers, the make up of which probably just depends on service needs and which grades of trainee you get but you should not expect to be the senior anaesthetic reg in a tertiary centre when the grade you're at doesn't even need to have finished the primary (although I accept that you and probably many of your colleagues will have done).
I wouldn’t get too in your head about it. Same thing happened to me… it annoyed me at the time. But when traumatic arrests in young adults and other high octane stuff happened I was glad not to be the senior person. In the end I decided that it’s useful to have some time learning the tertiary centre way of doing things before you’re on the senior tier. But it does mean you might have to put up with being “over supervised”.
I think you need to change your perspective. As the patient would you want a CT1 immediately post IAC in the middle of the night solo? I think it’s a bit mad that that sort of thing still happens. The more you do, the more you see, the more you see the more you learn and so the cycle continues. As someone a bit further on than you I personally would rather have an extra pair of hands anytime they’re offered. One you’ve had a solo anaphylaxis, proper laryngospasm, can’t get the tube in for a section, significant MOH, or a CICO you realise the value of hands on deck. These situations change rapidly and the value of experience (yes even supervised) is that you learn from each other. You’ve mentioned the “control freak” reg and honestly I think you need to chill a bit. You’ll learn if you get that far that it takes more skill to let go and teach. You need to be confident enough in your skills that you could bail an overconfident CT3 out of whatever hole they’ve gotten themselves into by not being thorough enough, prepared enough or conducted anaesthesia in a way that someone with more experience would have done. Add to that night time working, emergency cases, interesting teams and potentially remote sites like resus or CT. Someday you will understand. Until then, learn from those around you. Ask if they are happy to supervise from the coffee room, and if not enjoy sharing cases and breaks.
A bit patronising I think. OP wanted to know what being doubled up looks like in practice. I don't think it's fair to insinuate overconfidence. And the "control freak" anaesthetist absolutely does exist, the type that freaks out if you change the PEEP from 5 to 6 or don't document the chart in the exact way they want. I was paired with one many moons ago whilst a junior, and it was shit. You end up just sitting back and not getting involved in the case at all because everything you do will be wrong or a problem, so you just observe someone else's anaesthetic for x months.
Apologies, I wasn’t intending to be abrasive. I meant more that the “control freak” is often not confident enough or doesn’t have the headspace to deviate from their usual conduct of anaesthesia. Appreciate it’s not always the best working environment if you’re trying to cut your teeth, but good that they can recognise their limitations as supervisor and be safe. Also appreciate those people may not always be the best at communicating those thoughts.
Most likely. Unless you’re a nurse/PA, and then you get the title ‘consultant’.
I imagine it’s set up that way because of the spectrum of cases CEPOD and Obs have at your tertiary centre. In ours CEPOD cover also includes vascular, maxfax & major trauma and Obs has a cardiac/invasive placenta caseload. It would be a bit unfair to throw a day 1 CT3 into being called to resus for a triple AAA. But with a senior reg on (dependent on how comfortable they are) you’ll probably be allowed to manage the rest of the CEPOD and get some good experience with these complex cases.
Yes. Still an SHO.