This (very good) thread from @DrPhilipJSmith has spun out a number of discussions about Med Regs not calling their consultants overnight, and that this is 1) a bad thing and 2) due to hierarchies.

I think this is an important discussion - here’s my tuppence-worth https://twitter.com/DrPhilipJSmith/status/1340411828262883328

I have also called on call med consultant 3 times OOH in training:
1 - complex escalation decision for deteriorating patient
2 - service discussion about directive from manager to redeploy to ED
3 - XFR of patient req external pacing when just me or FY2 could go for XFR

I have wracked my brains, and honestly I can only think of one other case where in hindsight I should have called consultant (although they wouldn’t have changed anything in the management plan given PTWR discussion)

I see a lot of comments from intensivists who are bemused that med regs do not call more often, particularly about escalation discussions. I think a lot of this stems from the feeling that they must call their bosses so we should call ours. I think this is a false equivalence

The decision to discuss a patient with the ICU registrar overnight is about deciding whether that patient may benefit from therapies on ICU. I would argue that 5-10 years of medical training, which most registrars will have had, should equip one for this in most circumstances

The decision to admit to ICU clearly also involve specialist knowledge of therapies and prognosis, as well as resources and service implications. In ICU these decisions seem to be made at the consultant level. It’s not my place to comment on how other specialties do their work.

Clearly if there is a mismatch in opinion about whether a patient will benefit from ICU, then contacting the med consultant is needed. As I said, I have done this once in 3 years of med Reg.

To be honest, most of the rest of the work of the med Reg out of hours Does not require immediate gen med consultant input. Indeed I am much more likely to require advice from other specialty services (cardio, Gastro, stroke, ID/micro) overnight. Most stuff can wait till morning

So, on point 1, I don’t think that the infrequency of med Reg Calling their consultant at night is a bad thing.
On to point 2 - is there a hierarchy that needs flattening? Are people “scared” to call the consultant?

Honestly, I think some are. Part of this is where we work in fractured teams, it’s very hard to call the boss at three in the morning if you’ve ever met them. I like @AcuteMedEd and @adamfeather2 Discussing a physical check in or phone call late at night. I find this really helps

Unfortunately they’re still are consultants who give off force field vibes and make it quite clear they consider being contacted a weakness. This needs to go. It is the least experienced who need to feel they can call if needed they will be most put off by such behaviour.

Another argument used is that the medical consultant should be a gatekeeper, and that you shouldn’t contact other services without speaking to them first. This is rubbish.

I’ve done Gastro NROC on calls for several years. I get called about and by all sorts. Quite right too.

People call me either for specialised advice, or about decision-making around intervention. If people have these questions, I want to hear them. Of course we all have funny stories of silly calls, but I would rather that than put up barriers. e.g. #RegOrAbove rules @Microbedoc2

Interestingly, I more often call my boss as Gastro reg than as med reg. That is as it should be. I’m making high-risk interventional decisions with significant resource implications. The referrer just needs to say ‘they’re bleeding lots, help’. I don’t need their boss for that.

Finally, there is a discussion to be had about quasi-independent decision making as important for training and development, and a trend of infantilisation in medical training.

Clearly needs to be balanced with patient safety and flow, but, for instance, the drive for daily cons WR means some FYs I have met have NEVER done their own ward rounds.

Even first year Med Regs have been working for generally 5+ years!

So, in sum:
1) I’m not sure I agree that med regs don’t call their bosses enough.
2) there is a difference between a specialist Reg (ITU, Gastro) calling their boss and a med Reg calling theirs
3) we need to make sure people are happy to call when needed #culture

Any other med regs want to give their perspective? I recognise I’m just one person, with a particular set of experiences, and I may be outlier.
@RCPL_trainees @MattRoycroft @SusieBrockbank @AddyMcleod @rachelcjones @MeganLizi @Fat__Sister

- sorry for such a long thread!