Inside the Mind of an Acute Medic

Blog: Ramblings of an Acute Medicine Doctor - Transition from Registrar to Consutlant

“You’ll be receiving an email from HR here shortly with an invite to complete an application for a consultant job.”


This was the starting sentence of an email I received on my Son’s 3rd Birthday. Whilst not completely unexpected, it was about 6 months earlier than I had anticipated. It was this email that I feel the transition from Registrar to Consultant started for me, and it was overwhelming. I knew the ‘Grown Up Interview’ was inevitable at some stage but it had always felt like a theoretical concept, something we talk about but never actually happens. It was the most nerve wracking 6 weeks of my life. Those 6 weeks flew by.


It was sheer elation when I heard the words “we’d like to offer you the job”. I was on holiday in the Malvern Hills (covid was not going to ruin this trip), had just conducted the interview over a 4G connection as the WiFi was unacceptably awful and my family had just returned from their coffee trip, trying to keep tyrannical children out of the house during the interview. Relief and excitement, with everybody present to celebrate it too. It was perfect.


Fast forward three months and here I am, typing this reflection seven days before I am due to start my ‘acting up’ period. I am not a huge supporter of the term ‘acting up’. It sounds like somebody referring to a teenager going through their rebellious phase. I am very lucky to be finishing my ST7 at the same Trust that I have been appointed a Consultant. I have had fantastic support from all of my colleagues over the last three months. I have been supported in developing my own way of working. Identifying my own deficiencies and developing my strengths. It has been really rewarding to hear people say “Kelham is in clinic today, it’s like having another Consultant so everything will be fine”. However in seven days this will change. In seven days I am no longer “another” Consultant, I will be THE Consultant. That is terrifying.


There aren’t many (if any at all) written resources out there for this time in our careers. Sure, we have the advice and guidance of our peers, colleagues and bosses. But we’re Doctors. We want hard evidence, facts and something concrete to lean on. That is where the idea for this blog/diary/reflection (whatever you want to call it) came from. I don’t profess that this will be of the highest quality English and my grammar is definitely sub-par, it certainly won’t have academic rigour. However I hope it does provide somebody somewhere reassurance that all of the thoughts that run through your head at random points in the day are normal. That it’s okay to be scared and it’s okay to not be okay. If nothing else I think this will be more of an outlet for me, and that’s something.


I hope to talk about all of the things we’re too scared to talk about. Too scared to share with each other for fear of judgment or ridicule. With that in mind, I am very open to constructive criticism but please make it constructive. I don’t want a pile on akin to that seen on #MedTwitter. If you are reading this (and if anybody more than my Wife is reading then I will consider it a success), and if something has struck a chord with you then please get in contact. I would truly love to hear from you.


My name is Kelham Slinger and I am currently an ST7 Acute Medicine Registrar in Wessex. I am also one of the SAM Trainee Representatives. In August I was delighted to accept the role of Consultant in Acute Medicine at University Hospitals Dorset NHS Foundation Trust, you guessed Dorset. This Trust currently has two acute sites- Royal Bournemouth Hospital and Poole Hospital. I am currently working as a Registrar in Bournemouth but my ‘acting up’ period is taking place 8 miles down the coast in Poole which is also where, for now, my main place of work will be when I CCT. I have a truly magnificent Wife, currently on Maternity leave and is a Geriatric Medicine Registrar, and two children aged 3 and 5 months. I live on the outskirts of the New Forest and enjoy exploring it whilst running (an insane hobby I have only discovered in the last 6 months).


This blog will document my experiences, thoughts and reflections of the transition from Registrar to Consultant. The aim being to help other Registrars with this transition and acknowledge the challenges we all face but perhaps don’t talk about.


@KelhamSlinger- Twitter

Date uploaded: 28/10/2021

“The patient’s systolic blood pressure is 60 and they’re looking a bit clammy…”


It took a bit of time to say ‘Hi, my name is Kelham the Acute Medicine Consultant” but we got there. I continually feel like I am waiting for somebody to jump out and laugh at me for falling for a ridiculous joke. I guess that’s Imposter Syndrome for you?


I am constantly apologising for asking others to do tasks. Tasks I would ask of others when working as a Registrar, but now feel like I am imposing. The first Lumbar Puncture I deemed necessary is a perfect example. For the first time in my career I advised a patient they needed a Lumbar Puncture but was not going to be the person performing or supervising the procedure. I looked at the team and asked who was comfortable doing the procedure. The team’s immediate response was nobody, but someone starting at 2pm would be. At the 2pm handover I then sheepishly asked if they could please very kindly do the LP. Of course the response was a very enthusiastic ‘yes!’ but I still felt like they hated me just a bit inside (I am sure this is not actually the case but my own crippling insecurities). I need to work on owning my new role within the team and appreciate that perhaps my skills are now better served elsewhere. More evidence of that Imposter Syndrome…


My first day was very reasonable. A steady ward round with an excellent team, effective management of patients through SDEC and good acuity on the take. The second day less so. I arrived at midday and there were a lot of outstanding tasks, including several procedures. The ward round had been challenging and more bodies were needed. I went off to go and observe a trainee perform a procedure in ED in order to tick their ePortfolio competency. Whilst we were discussing the procedure outside of the room the nurse caring for the patient popped their head out and said “The patient’s systolic blood pressure is 60 and they’re looking a bit clammy.” Cue panic. I have deliberately kept details vague to ensure patient confidentiality but this was a procedure I was familiar and comfortable with, but do not perform on a regular basis to any extent. The trainee was not overly comfortable with the procedure and in a less urgent scenario would have been more than capable with my supervision. However the situation had become somewhat more urgent and I took over. I’ve always struggled with somewhat of a hand wobble when doing procedures (surgery was never going to be the career for me) but this was a new level. Needless to say, I needed to change my scrubs afterward. It all went smoothly, the patient was far less sweaty by the time I had finished and I got an overwhelming sense of achievement. Upon reflection, this interaction was my bread and butter. Something you get very used to as a Registrar, dealing with acute issues and attempting to rectify them. I knew what needed to be done and achieved that. It felt good to have that win.


Dealing with uncertainty is something I struggle with. I have full insight into this and will be focussing on that over the next few months (any hints or tips are very welcome!) Uncertainty is ever present in our work within Acute Medicine. You can never definitively prove that the chest pain is musculoskeletal in origin. You rely on the patient’s history, examination findings, investigation results and your clinical experience to aid you in that conclusion. But you can never truly prove it. I have of course simplified a very complex decision making process, but it is an attempt to explain why I struggle with uncertainty. I am confident and comfortable when a positive diagnosis is evident (i.e. a PE found on a CTPA for a patient presenting with pleuritic chest pain). When there is doubt, I struggle. There is no guideline for uncertainty, there is no score you can calculate or pathway to follow. Uncertainty requires clinical experience and being put in that position time and time again. I have an excellent group of colleagues to discuss cases with and have no issue approaching any of them. Their experience is invaluable for me. Just before I started ‘acting up’ a Consultant told me “Never stop asking questions, in fact, you probably need to be asking more questions when acting up than you do as a Registrar”. This was exactly what I needed to hear.


Lastly, I have been trying to find my own way of working. I have been fortunate to work with many very good Acute Physicians and observe their very different approaches to managing the various facets to Acute Medicine and the art of the post take ward round. I don’t think I have quite found my comfort zone yet but have been trying out different styles. Be proactive and review patients without their full investigation results being available? Stand back and wait for all the results before I see them? Clerk patients directly myself? There are positives and negatives to all of these approaches and I don’t think I have a strong pull toward any of them. Personally, I think all approaches probably have their place at the right time. I try to avoid duplication and expect a medical SHO to ‘clerk’ the patient when an ED SHO has already seen them for example. Equally, my assessment is probably less useful the moment a patient walks on to AMU from the community than if a triage assessment is made first and initial investigations initiated prior to me seeing the patient. There has been so much to get my head around in the first week. I think I am coping, only time will tell if that continues.


This blog will document my experiences, thoughts and reflections of the transition from Registrar to Consultant. The aim being to help other Registrars with this transition and acknowledge the challenges we all face but perhaps don’t talk about.


@KelhamSlinger- Twitter

Date uploaded: 28/10/2021