Becoming the medical registrar: what I learned – and what needs fixing

In 2021, I was an ST4 in acute medicine, and a final-year student on the MSc in medical education, a programme designed by the Royal College of Physicians (RCP) and University College London. For my research thesis, I chose a topic that I’d been fascinated by for a long time. I set out to explore how doctors in stage 1 internal medicine training (IMT) experienced the difficult – and often needlessly mythologised – transition to become the medical registrar.

2021/22 was the first year of IMT3. Expectations were high. Literature suggests that residents on the old core medical training programme had long felt unprepared for the step up to registrar. IMT3 was meant to fix that. Did it?

Myth and reality

Ask any FY1 what they think the medical registrar does and you’ll hear a mixture of awe and fear: ‘the final bulwark against catastrophe’, ‘the fount of all knowledge’, ‘who you call when all else fails’. I’ve heard these clichés many times, and I felt the burden of that myth as a new registrar myself.

The data that I gathered revealed something more complicated – and far more interesting. As those of us who’ve held the bleep understand all too well, the medical registrar is not all knowing or all powerful. A good med reg knows who to ask, what to prioritise and how to get things done under pressure. They don’t know everything. And honestly? They don’t need to.

To become the medical registrar, doctors must first redefine their understanding of the role. What does that process look like?

Eight stages of transition

In writing my thesis, I began to see that some experiences were universal. I found that there were eight stages which all doctors go through to become the medical registrar:

1. Insurmountable task: to an FY1 or FY2, the registrar role appears impossible, a standard that they could never meet. Sadly, this puts many off pursuing careers in internal medicine. 
2. Master of one world: by the time they reach IMT2, doctors have become capable SHOs, but are often stuck in a ward role indistinguishable from that of the FY1. They itch for more responsibility.
3. Crossing the threshold: medical hierarchies are notoriously rigid. Eventually, one must leave the SHO rota and join the registrar rota. For some, this is a step willingly taken. Others are thrust across this threshold before they feel ready.
4. Strange new world: the first few shifts can be profoundly disorientating for experienced doctors used to feeling adept as senior SHOs. They enter a stage of conscious incompetence, more aware of the skills that they need to develop to perform.
5. Embodying the role: it only takes a few shifts for new registrars to prove to themselves that they can do this. They may not yet feel that they can excel in the role, but they can perform it adequately, and that is enough. For now.
6. The first trial: it’s only a matter of time before something goes wrong. Perhaps a mistake, a conflict with another specialty or an unexpected death. At this point, doctors are vulnerable. Good, non-judgemental supervision is vital at this critical moment.
7. Master of two worlds: as time progresses, registrars come to understand that they have only so much control over how well – or badly – things go. Once they come to terms with this, they can find their own style and begin to enjoy the autonomy afforded to them.
8. Freedom to learn: ultimately, doctors realise that the registrar role is not the destination. There is no end point. Learning is a lifelong process that will span their whole career.

What this means for training

Educational models are nice. But they only matter if they have real-world benefits. And the message from this study (now 3 years old, but still very relevant) is clear: our IMT doctors don’t feel that we’re doing enough to prepare them for life as the medical registrar. 

I often get asked whether simulation is the answer. I’m not convinced that it is. Simulation can provide concrete experiences for doctors to reflect on and learn from. But new medical registrars are having experiences all the time. What they lack is structured feedback, and the psychological safety to reflect on and learn from their mistakes. 

The most important training takes place on the shop floor, where doctors learn to manage uncertainty, prioritise risk and make safe decisions with incomplete information.