A year ago a Critical Care SRMO was falling out of love with their dream specialty and chose a different path. Turns out, it was the right decision.

Cold Feet

12 months ago I was in the midst of a crisis of faith—which you can read about in excruciating detail here. Having devoted the last five years of my life to securing an anaesthetics training position, I was staring down the barrel of annual medical recruitment with ice cold feet. I no longer felt the same spark, and the thought of embarking on the arduous and gruelling journey of anaesthetics training without passion to power me was nauseating. I felt that I was past the point of no return. I had come this far, I simply HAD to apply. And if I were offered a position, I HAD to take it. While my fellow anaesthetics-keen colleagues were anxious about missing out, I was hoping to fall short. To bow out due to circumstances beyond my control; to be “unlucky” instead of a quitter.

I ruminated on this for several weeks, and made the hard decision to turn my back on my dream, opting to try out Emergency Medicine instead.

Breaking the news

I told my parents first: “Aren’t you already training to do Anaesthetics?” – as non-medical people they are blissfully ignorant to the complexities of medical hierarchy and the distinction between “Critical Care SRMO” and “Anaesthetics Reg” was pretty meaningless to them. While they may not have understood the specifics, they were nonetheless supportive of my decision. This outside perspective was quite refreshing – they had no preconceived notions on the “value” of certain specialties over others, nor have they acquired the distaste for quitters, failures and washouts that is so pervasive in medical circles.

Such unconditional love is sparse in the medical world, and as such I was scared to break the news to any of my “work only” friends, let alone my seniors. My original article was my “Quitter’s Manifesto”. Behind the shield of anonymity, I was able to process my conflicted feelings and examine the internal and external factors behind my anguish. In sharing the blueprint of my own decision, I wanted to find my own truth. I hoped that people could empathise with my struggle, and those in a similar position would find some guidance to help them make the right choice for them.

In my real life, I kept quiet, well into the recruitment period. I did not apply for anaesthetics, and instead interviewed for an ED Registrar position. I kept my head down for the final weeks of my anaesthetics rotation, and dodged questions from other Critical Care SRMOs about what jobs I applied for. The Anaesthetics primary exam was a welcome distraction, with all the consultants too distracted by which trainees had passed or failed to concern themselves with the career ambitions of a lowly resident. When job offers came out, the topic couldn’t be avoided any longer. I had decided to become an ED Registrar, and ready or not I had to tell people.

As it turned out, anxiety over career direction was a common theme among my cohort of Critical Care SRMOs. Like me, many had shifted their focus away from their “first love” and opted for a different direction in critical care. Some would be joining me in ED, with a few even opting to pursue physician training or GP instead. Evidently it wasn’t just me who had struggled with a crossroads decision about which training pathway to take, as well as the apprehensiveness and shame associated with voicing their doubts publicly to their colleagues. We had all been hiding the same thing from one another.

Owning my decision

Life for me post-washout was good. Having committed to a “trial year” as an unaccredited ED registrar, I felt a weight had been lifted off my shoulders. I had enjoyed working in the ED a great deal. The work was varied and stimulating, and the department had a strong culture of promoting employee wellbeing and encouraging work-life balance. The attitude towards training positions was far more relaxed and realistic – as long as you were competent, professional and willing to learn, you would always be welcome in ED. There was no need to buff your CV with Master's degrees or conference presentations, just to get your foot in the door. Outside experience was valued, and taking time off from ED to pursue other interests or just to have a life was not grounds for excommunication.

I was looking forward to life as an ED Registrar. On my ICU rotation I had started to step up to making more decisions with supervision from an arms-length and assessing and making plans for patients in the ICU, and even running the show at MET calls. It was easy to talk about my future in ED with my seniors in ICU – I had a blank slate after all, and I had no concerns about disappointing them with my last-minute lane change. I began opening up more about my change of heart, and found many sympathetic ears among ICU doctors who had similarly turned away from anaesthetics or physician training only to find their people in ICU. I had become more comfortable with talking about my chosen direction. But I still had one more anaesthetics rotation to go, and I was dreading breaking the news to consultants who had supported me along the way.

The first week was excruciating, with every day featuring the same Greatest Hits: “What are you doing next year?,” or “I thought you wanted to do Anaesthetics?,” and the classic “Why on earth would you want to work in ED?” 

While I still felt confident I had made the right decision, the constant barrage of disappointment from senior doctors who I had worked with in the past was exhausting. A common theme emerged – they were not disappointed that I had squandered my potential or that I would have been well suited for anaesthetics, they simply found it abhorrent that I, let alone anyone, wouldn’t want to do their specialty. I found that easier to swallow — it wasn’t personal after all. 

Meeting with my supervisor midway through the term, I expected the same line of impersonal questioning. After rattling off my well-rehearsed line of “I enjoyed anaesthetics, but I felt I was more suited to ED,” I was met with unexpected endorsement. “That’s great news”. I was not the first resident he had seen turn away from anaesthetics. As he put it, there were different flavours of critical care, and certain things appealed to different people. Where I had expected disappointment, I was met with acceptance. “The point of residency is to try on different specialities. It’s ok if some things don’t fit.”

Ultimately, this was the opinion that mattered – one that took into account my personal circumstances and feelings, and not those that were disappointed because I decided to play for another team.

My first 6 months as a registrar

Fast forward to February 2021. The transition to ED Registrar was quite a shock. While I was familiar with the workflow in ED and how this particular department ran, I was not fully prepared for how gargantuan the jump in responsibility would be.

Being “in charge” of a section of the ED during a shift was quite daunting. Supervising junior doctors, some of them interns on their first ever term in the hospital, consumed a lot of brain power. Being aware of the goings on of all the patients in my section of the ED, managing constant interruptions to review ECGs or deteriorating patients, and helping to formulate and execute plans for other people’s patients saw my effective workload per shift balloon dramatically from my resident days. All the while, the previous yardstick of how effectively I was working – the number of patients I had personally seen and sorted out per shift was the lowest it had ever been. The first weeks were intense, and my confidence, as well as my self-care and lifestyle, took a huge hit.

I was fortunate to be working in a department with a very top-heavy registrar roster, with many advanced trainees poised to sit their fellowship exams. The bulk of the workload was being shouldered by senior doctors, allowing myself and the other first-year registrars to properly settle in. While I was stressed, there was always the lifeline of a readily-available ED consultant if needed.

Somewhere around the 3 month mark I got the hang of supervising juniors – I learnt how to distill a convoluted story into a set of differentials, how to take a high-yield history, and how to formulate a safe and effective plan. Most importantly, I learned how to appropriately delegate tasks to keep myself free and mobile.

Teaching has always been a passion of mine, and being able to teach procedures like ultrasound cannulation and plastering to junior doctors, and then being able to delegate these tasks later in the term and watch them confidently complete them has been a great source of pride for me this year. I have even had the chance to mentor new interns and help them through the daunting prospect of their first ED term.

I still lean heavily on my seniors for support in hairy situations, but day by day I can feel my scope of practice expanding. The teething period is well and truly over, and the number of patients I am seeing per shift is higher than ever. While this job is by no means easy, I feel more comfortable in my role, and don’t feel like as much of an imposter as I did 6 months ago. 

New Challenges

Emergency Departments in Australia are busier than ever. The hangover from Covid-19 and the knock-on effects of delayed treatment for serious illnesses, reduced access to primary care services and the ever-worsening state of access block in hospitals overflowing with patients have resulted in an unprecedented number of ED presentations, with more high-acuity patients than ever before.

My home ED is currently experiencing the greatest swell of patient presentations in its history. Two weeks ago we broke our record for most presentations in a 24-hour period, and routinely we are seeing numbers close to our previous all-time high. There is little evidence that things will slow down any time soon

Solving this problem will require long-term solutions. While work is stressful at the moment, I feel that I am where I want to be. This “trial year” has been a success for me – I will be applying for an accredited ED position in 2022 and will officially begin my training.

While I have gained a sense of closure, I have also gained perspective. Another registrar I work with was in a similar situation to me 12 months ago. They have decided that ED is not for them, so will be pursuing ICU training instead next year. Others I am training with have had careers before ED – surgical training, GP, even a former cruise-ship doctor. Some senior trainees have taken time off to travel or have children, some work part-time. While it may seem like we only have one shot, evidently the long way around is a legitimate option.