Registrar training can be a real minefield to navigate. It feels like a truly all consuming process that can leave you struggling to pick up the pieces and figure out if you’re coming or going. I go into pretty honest detail in my own review of my first year of training which I’d recommend reading first. But I’ve written this article as a starter for ten to offer a constructive way of approaching this career stage. The contents and advice herein are all drawn from my personal experience of starting registrar training, where I felt very new and junior at the beginning, but slowly learned and optimised through trial, error, and improvement.
First and foremost, you need to review the portfolio requirements that are assessed by your deanery. Usually, each deanery has a checklist that you can follow. It’s imperative to know what portfolio targets you need to hit in order to continue progressing through training. This is particularly critical if you want to be as organised as possible and continuously demonstrate progression as well as achieve the expected competencies by each waypoint.
Next, it’s useful to approach your training like this: two halves – ST3-ST5 and ST6-ST8. I realise this corresponds to the nodal point (pay scale) pattern as well, however, it’s actually a bit more handy than just that. See below👇🏽
ST3-ST5
For me, this part of the training programme felt pretty tough; a very much “oh wow, what’s just hit me” type phase. I think it’s important to focus in on this stage of training since it’s easily a time where burnout is around almost every corner. Again, click here for my exact feelings and experience.
ST3-ST5 is the period where you make the jump to registrar and really feel like you’re working in your specialist area of interest. Finally, you’re a trauma and orthopaedic surgeon. It’s the time where you learn how to do the job, how to manage the increased responsibility, and how to identify and establish your own working rhythm. You develop your leadership style, your technical and non-technical skills, your efficiency, and organisation. Your focus during this phase is to learn the basics, such as routine trauma operating and managing the emergency take and ward rounds. Things like clinic and elective operating will vary due to temporary rotational stints in each subspecialty, but you’ll develop a broad understanding of what each subspecialty entails.
However, it’s also the time when you hit the toughest parts of the Dunning Kruger curve. At first, you’re unintentionally traveling in the “unconsciously incompetent” lane, generally living life and grinning from ear to ear. Ok, there are a few high expectations, but it feels so good to step up from feeling a bit like a spare part during CST and instead actually being allocated to the operating theatre and clinic.
But before you know it, the rose tints fall off your glasses. You start to see that it’s not quite the free ride you thought. The training requirements are tough, the expectations on the frontline are even tougher. But toughest of all is the learning curve. As you start to rotate around each specialty, it becomes progressively more apparent how much there is to know. You enter the dreaded sticky “consciously incompetent” phase of the DK curve towards the end of ST4 into ST5. The job itself is now pretty doable, however, you’re acutely aware of what you don’t know especially when you grow closer to being quizzed on FRCS topics during trauma meetings and regional teaching sessions.
Anyway, there are key things you ought to focus on during this time. I have outlined a list of priorities below:
- Trauma operating. Focus on getting really competent at routine trauma. Develop a well rounded understanding of the principles behind each common trauma operation and how to do it well and efficiently. By the end of ST5, the aim is to achieve, or be as close as achieving all the SAC numbers for routine trauma e.g. hip fracture surgeries, plate fixation, intramedullary nails. You should also tee yourself up to achieve level 4 PBAs across the board for most general trauma by the end of ST5.
- Audits. Focus on boxing off two closed loop audits. It’s not actually that arduous to complete two audit cycles during one six month rotation, it’s just a bit of an annoyance, especially when you already have the job to get to grips with. But starting early, i.e. literally in the first month of commencing the rotation, will mean you have just enough time to collect data, present your findings at a monthly audit meeting, and do the whole thing again with enough of an interval between cycles to allow for meaningful change. I’ll let you into a secret: audit compliance of routine trauma surgery operation notes against the Royal College of Surgeons of England Good Surgical Practice guidelines. You can thank me later…
- Research. Start getting stuck into a research project nice and early too. These can take a while so start sooner rather than later so as to not have to chase it at the last minute. Identify who the academic surgeons are in your region and request a meeting to discuss any publishable projects they may have that you can join.
- Work place based assessments (WPBAs). Finish all of your WPBAs on Critical Conditions. Aim to achieve level 4 Procedure Based Assessment (PBA) for arthroplasty and almost all routine general trauma index procedures. Aim to achieve all of your level 4 CEXs for Consent as well as general CEXs for most common examinations e.g. hip, knee, shoulder, spine, etc. CBDs should be focused on key FRCS topics that are not included in the Critical Conditions or interesting cases.
- Knowledge. Personally, I think the main focus should be basic science. Basic science traverses all of the subspecialties and so will help you understand the background, or the “why/how”, behind T&O surgery without limiting yourself to learning about one subspecialty. It essentially lays the foundation for a lot of the clinical knowledge you’ll learn over time. Try to attend a course or start reading the chapters in a textbook or on Orthobullets (no paid endorsement, just personal opinion). Ramachandran’s Basic Science book is the most commonly used text (no paid endorsement, just personal opinion) and the Basic Biomechanics in Orthopaedics (BBiOrth) course is one that I attended and really enjoyed (again, no paid endorsement, just personal opinion).
A further breakdown on what you can focus on per year is shown below. Feel free to use this as a guide for your personal development plans:
| ST3 | – Learn how to perform hip fracture surgery well. Aim for a level 3a PBA. – Learn plate fixation of simple ankle fractures. – Learn plate fixation of distal radius fractures. – Aim to complete level 4 WPBAs for the following Critical Conditions: compartment syndrome, necrotising fasciitis, cauda equina syndrome, major trauma resuscitation and physiological response to trauma, and diabetic foot. – Conduct a closed loop audit. – Engage with teaching and complete an OoT – deanery teaching for CST trainees is always a great way to obtain these and helps to give back to the programme. |
| ST4 | – At least 1 level 4 PBA for hip fracture surgery. – At least 1 level 4 PBA for plate fixation e.g. simple ankle fractures / distal radii. – Level 4 for all CEXs for Consent. – Level 4 WPBA for at least half of the Critical Conditions. – Conduct a second closed loop audit. – Start a research project. |
| ST5 | – At least 1 level 4 PBA each for hip and knee arthroplasty. – Level 4 PBAs across the board for hip fracture surgery, long bone fracture intramedullary nailing, and plate fixations. – Level 4 for all CEXs for Consent. – Level 4 WPBAs for all Critical Conditions. – Start light reading for FRCS (second half of ST5). |
ST6-ST8
The focus for this stage of training should be the FRCS exam, sub-specialising in an area of interest, and applying to fellowships. By this point, most of the general T&O portfolio requirements should be achieved so you can focus on the exam and tidying up the remaining loose ends. It’s important to disclaim that it really isn’t the end of the world if all the portfolio requirements aren’t completed; training is complex and achieving all the competencies like clockwork is not always possible due to multiple factors. But this just serves as a guide to show how important it is to box off most of the general portfolio requirements for broad based T&O training, since this can take a while and the last thing you want to be doing is chasing WPBAs and audits when you’re also trying to revise for the exam.
Prior to the second stage of training, you want to have set yourself up for a clear run where you can solely focus on the exam without distraction or the risk of being held back due to inadequate portfolio evidence. Granted, you will probably still have a few more subspecialty rotations to complete before sitting the FRCS examination, however, you will want to be focusing on the exam anyway during this time. When you’re peri-exam in ST7, you should then be able to start focusing on your subspecialty area of interest.
A further breakdown on what you can focus on per year is shown below. Feel free to use this as a guide for your personal development plans:
| ST6 | – Aim to have completed almost all mandatory subspecialty rotations by now, usually there will be one or two left. – Start revising for the FRCS exam – setting up a study group is a good idea. – Think about your subspecialty of choice and start to declare this interest to your TPD/supervisors. |
| ST7 | – Sit the FRCS examination. – Commence rotations in subspecialty of choice. – Start applying to fellowships. |
| ST8 | – Have a fellowship arranged / – Start making enquiries about consultant jobs / networking with centres in own region or region of choice. – Complete CCT checklist and achieve competencies demonstrative of day 1 consultant across the board in line with deanery requirements. |
So, I hope this general overview is a helpful starting point on how to approach T&O registrar training. Despite the esoterica of the training requirements, I suspect a lot of the concepts might also have some applicability for other specialties too. Either way, I would have found a lot of this really useful at the beginning of my registrar training so I hope I can help others through this “what I wish I knew” style guide.
Feel free to reach out and ask any questions or send any tips you might have yourself!
Vasudev Zaver 