A 50-year-old man presented to a regional hospital 3 days ago with fever, shortness of breath and cough. He was subsequently diagnosed with community-acquired pneumonia. He had progressive respiratory failure necessitating intubation, mechanical ventilation, deep sedation and neuromuscular blockade. His chest X-ray showed extensive bilateral infiltrates. He remained profoundly hypoxaemic (P/F ratio 75) despite optimisation of ventilator strategies, antibiotics treatment and appropriate fluid balance management. He required low-dose vasopressor support. The hospital made a referral for V-V ECMO initiation.

Introduction

This whole post is entirely made up. Be warned. It’s built from my own experience and reflection on the CICM’s transition year and it’s written almost as advice to myself at the start of the transition year from myself at the end of the transition year. As such, I hope it resonates with you or at least proves useful as a guide for someone starting off in their transition year! So what actually is the Transition Year? I mean we all know it’s the final 12 months of training with the CICM. In actual fact it’s a bit like a test drive before you buy a car. (I’m still not sure in that metaphor if you’re the driver or the car – probably both). Basically, you can see it as a year-long opportunity to be a consultant in a specific ICU while having a big safety net. At the same time, it’s also a year long job interview – the stuff you achieve here in your clinical time and, importantly, non clinical time lets the ICU world know how you will perform as a consultant. 

Discuss 

Consultants chat… a lot. It’s a difficult job and you’d be surprised how much discussion happens in the ICU offices behind closed doors. We just never see it as trainees. Even the very senior doctors do it! I’m serious – I’ve seen world-leading Professors of subspecialties confess openly they have no idea what’s happening and ask for help!  So don’t you dare be afraid to be unsure. That’s why I’ve put this point first! If you’ve got a patient that you’re not sure about or if you feel that you’re stuck between a rock and a hard place then go ahead and chat. Especially as a transition year trainee (and I reckon as a doctor in general), never make decisions outside your comfort zone. I suspect this is the exact reason that consults were invented! Once you’re comfortable enough to discuss with other intensivists you’ll notice that you actually have a much wider community of potential chat-mates: Your physician, surgical, anaesthetic etc colleagues feel exactly the same way and appreciate a good ol’ chat! 

Plan Plan Plan 

In the immortal (and obscure) words of Helmuth von Moltke the Elder, “no plan survives first contact with the enemy”. Recognising that, the plan you set out to accomplish won’t be the same plan you finish your year with. Deal with it. 

Nevertheless, planning your year out is vital if you want to walk away with something at the end of it – after all this is a great moment to prove your worth. The trick is to find a handful of achievable goals for the year (by which I mean ~3 main projects) and to make these goals SMART (Specific, Measurable, Achievable, Realistic and Timely). That way they’re more likely to ‘survive contact with the enemy’. 

But I hear you asking “What is it I should do”? Well, welcome to one of the simultaneously fantastic yet terrifying things of being a consultant – the choice is all yours. My thoughts when selecting my projects were: “Do I actually want to do this… like me, do I actually want it?” and “Will this ‘value add’ to the department?”. More on this later in ‘finding the crisitunity’

Organisation 

Yeah, this overlaps a bit with plan plan plan, but there’s a difference. What I mean here is organising yourself, your day, your week and your year. 

There are a million ways and systems to pick from: Calendar apps, Google drive, Apple notes, pen and paper etc. I honestly don’t think there’s a right or wrong one, so just pick one and try it. You can always change later. Personally, I’m a bit of a dinosaur in this respect. I have a diary for the year in which I write important dates and I build a list of objectives to achieve in a spreadsheet (Basically it’s a big to-do list). Each week I had a look at the running list and thought what could I do that week to move things forward and built a to do list from there. I checked that list daily to tick things off and build a plan for each day. Some days I achieved nothing, some I finished the list for the week. It doesn’t matter how you do it, as long as you’re keeping track of what you need to do and when to do it you can see the progress you’re making. 

As an added aside I also used my email as the major inbox of my life – if I had a thought or if someone needed me to do something I’d have them email it so I wouldn’t forget (I’d even email myself) and so when I sat down to answer my emails I could add them to my to-do list. Also, if I needed to assign a task to a team member or minute chats or meetings with my mentors it made for a handy way to keep track of everything. 

Prioritise and balance 

To blatantly steal an analogy from my supervisor – “You have lots of balls in the air – life, work, sleep, exercise. You need to decide which ones to drop AND when” – i.e. the life ball might be important to catch this week because it’s a birthday or an anniversary but next week you might have to let it drop to catch a big due date for work. The key with this metaphor is It’s about balance – i.e. you have to prioritise different things at different times if you want that elusive work-life balance. 

I’d also recommend prioritsing the commonly forgotten ‘sleep’ and ‘exercise’ at the high end of things than one would traditionally think. Aim for your 8 hours of sleep EVERY NIGHT and aim to do exercise MOST mornings. If this means you’ll need to get up earlier then go to bed earlier! Why mornings? – it’s harder to find that lame excuse of “it’s a busy day” or “not enough time” to exercise if it’s in the morning. If afternoons suit you better, fair enough. Just get on with it. 

Have some mandatory time off  i.e. 1 day a week. I never thought I’d be one of those people that worked too much but here I am. I had to learn this lesson the hard way early in the year and then a few more times. We’re all human, we’ve all worked hard to get here and we should enjoy some time, so make sure you line up a day to celebrate. If you can’t find time off this year then when in your next 30 odd years of being a consultant will you find it? In fact you might find the added side effect of being more efficient for having taken this break!

It’s also important to recognise that everyone relaxes differently – I personally needed a day of nothing to sit on the couch and not talk to anyone. If that’s what you need, then do it. If you need to be out golfing, shopping, hiking or gardening, well the choice is yours. You’re at the start of a very long journey (not the end!) and if you don’t take the time and responsibility now to learn how to listen to yourself then your journey will be short!  

Reflection 

Ok, so hear me out. This might sound a bit weird, but I found this really helpful in both growing and in recognising my growth throughout the year. Plus it gave awesome discussion points for the supervisor meetings! 

There are lots of ways to do this – I started a reflective journal. It was a book with lines in it and I would write about cases and events. I’ve never been one to write a journal and I didn’t know what I was starting when I did it. I wrote about cases I saw, lessons I learned and even weird conditions/cool techniques. To let you in on a secret I don’t think the content of the journal is worth anything – it’s the task of having to process your thoughts and reflect onto that page which really makes it worthwhile. 

There are lots of ways to reflect on what you do even if you don’t like writing on paper  – you could write a blog article (ahem, guilty), have coffee/brunch with colleagues or even play online video-games with friends and talk nonsense. I’ve tried them all. 

Find the ‘crisitunity’ 

Think of it this way – a problem for you/the unit is your opportunity to solve that problem and by doing this you will demonstrate your value. 

It sounds somewhat cunning and opportunistic but it’s really not – it’s just fixing problems. In my chats with other intensivists, directors and random doctors it dawned on me that this is how your non clinical value can be demonstrated. It turns out that everyone else who’s got an FCICM is completely qualified as an intensivist and can look after sick patients. So in essence what provides justification for you getting your consultant job depends on what else you can bring to the team – i.e. it’s your non-clincal life that sets you apart. If you’ve solved problems for your unit by testing out equipment, built a teaching program or helped fight off a pandemic with protocols, you’ll be well placed for the curveball questions when it comes time to sit the consultant interviews and better yet, you’ll be well placed for working as a consultant. Try and pick a few different topics as well to make sure you’re well rounded and experienced and have these as some of your goals to achieve over the year.  

The most difficult part of this is finding a crisitunity that fits your interests, but trust me, they’re there. As an example, I wanted to explore my interest in Neurocritical care. So I spent the Year (and a bit longer) writing a guideline for the management of Spontaneous subarachnoid haemorrhage and I organised a neurocritical care themed education day. Alternatively, if you’re interested in education or research you could formalise it by starting a graduate certificate or masters (note – I said “starting” – your year will be busy and part time university has been created for a reason!). 

Learn to say no

This is a hard lesson. It took me about ~2 months of grabbing projects until I was full for the year and couldn’t do more. The problem is it took me a little longer to realise this was the case (The problem with biting off more than you can chew is that it’s hard to know until you’re actually chewing).

The ‘no’ is important, but you have to find your ‘no’ yourself. We’ve been hard wired and selected through our training programs and medical school interviews to be high achieving type A people who can do everything. Now’s the time you need to control it. 

Why do I care enough to include this? Well taking on more doesn’t actually accomplish more, it only threatens the stuff you’re already working on! It all comes at an opportunity cost –  every yes you say for another small job will eat away at precious time you need for a big job or make you too busy to snap up that great project you always wanted when it finally comes along. Sit with that for a bit… Once I started rationalizing that I was threatening my other projects it became so much simpler to quiet the people-pleasing side of myself and politely tell others ‘no’ (thankyou). 

Be flexible

This is an artform and I am yet to master it, but being able to flex is key. You’ll be working a series of strangely timed and unpredictable shifts. So sometimes you’ll have the opportunity of not being busy where you can sit down and knock out some jobs. But you need to be ready for it! Sorry if it sounds like it’s from the 90s, but I think a laptop computer is a great investment and bringing this to work in case you have the chance to use it is important. If you don’t have the laptop with you, then think, what else can you do? Where else? When else? 

Get a life

Yeah this overlaps with organising yourself a bit but I promise I’m not running low on points to make it to 10 – it’s just important this stands out

I remember when I was preparing for my first part exam I was asked “what do you do for fun”, or something to that effect, and honestly, I had no reply – what could I say? “I’m studying for my exams… that’s my life”. The sad thing is that that was entirely true. I had nothing else in my life of note! 

So, please, for the sake of being a well rounded person just have something you enjoy outside of work. Anything! How did I go about picking something – well I thought about a few specific things I wanted – I wanted to learn something for myself and not the college and I liked listening to music but couldn’t play it – so I picked ‘learning to play the guitar’ and went for it. I also wanted to improve my fitness, so I picked a half marathon to do with friends and trained for it.  

The same thing happened at the start of my transition year – I nominated a few lifestyle goals – I wanted to improve my guitar to play specific songs, I wanted to beat my half marathon time, I wanted a good holiday, I wanted to take up astronomy (not great in locked-down Melbourne, but oh well). Once I had the goals I just inserted them into my ‘plan plan plan’ and worked on them weekly to achieve them. These kept me sane and offered a bit of down time away from the hospital. 

Oh and what’s that you’re saying – how are you finding time for this? When can I do it? If this is the case it means you need to re-read ‘Prioritise and Balance’, ‘Learn to say no’ and ‘Organisation’. Think of it like a phone – you’ll work a lot better when you’ve had time to recharge! 

PS. If all that wasn’t enough to convince you, I have it on good authority that some interviewing panels look at this info first as it sets candidates apart and gives you a good talking point in the interview!

Work as a team

Ok, I mean a few things by this. Firstly – Delegation: You’re now the boss. You need to be efficient, you’re leading a team, you have to think, discuss and plan and you’ll have a few things to do yourself – you don’t have time to put in cannulas! So don’t be afraid to assign jobs to the junior registrars but at the same time, remember to keep in touch with the team, follow up on tasks and that occasionally taking a couple of jobs from the ward round which are easier for you to do is sometimes the most efficient way for all. I had a big fear with delegating initially and instead split the jobs with the team – this did not work, so I had to get better! 

The second thing is to know your other fellows. Wherever you work might have a different name – “transition registrars”/”senior registrars”/”transition fellows” etc. The point is that there will be a few people going through the same ups and downs as you, learning the same lessons and maybe even having a few hints to help you out. I still talk to some of my co-fellows every Thursday and debriefing with them has been vital! 

Experiment 

This is your year to find your groove. Experiment with your ward round. Have a plan, if it works, great, if it doesn’t, flip things around.

Do you want to assign fixed roles for each member of the team (e.g. a writer, an examiner, a labs checker)? Do you want a runner to field jobs in the unit and deflect work away from the round while you and another registrar crack on with it? Do you want to set a timer for each patient? Do you want a nursing representative to join the round or would you rather chat with the NUM before kicking off? Do you want to institute a mandatory coffee break at 1030 to recharge or do you want to power through the round? Just try different things and if you like it then keep it, if you don’t then don’t!

One important side note to this is to be open to the idea of changing it up as the situation changes – for instance, if there’s a change in workload, patient case mix, team member skill set/experience level be ready to flex. Try not to get set in your ways as you’ll likely find that what works for one situation doesn’t necessarily work for every situation.

Whatever you decide, the one piece of advice I’ll give you is to be patient and expect a long round. A thorough round will eventually be good, but a rushed round will be forever bad. The speedy consultants who always finish early have been doing the job a long time and have their pattern recognition down. Instead of aiming for time, aim to be thorough. What does this translate to? For me initially, I would take 20-30 mins a patient. At the same time, remember you need to leave time for the registrars to complete their jobs before the windows are missed. I think the key to this balance is before you move on, make sure you either understand the patient or you have a temporising plan in place and then have a bigger think about it all after rounds. It’s ok to change plans after rounds and overall speed will come with time, I promise. 

Final words

So that’s it. It’s impossible to distill the whole year and all its lessons into 10 points and it’s oddly decimally artificial if I’m honest. I think no matter how long it’s taken you, where you’re working or what your job is called there’s one clear truth – you’re awesome! You’ve made it this far (through 2 exams, a project, an echo certification, countless courses and years of night shifts) so no matter what turns up you can do it!