I was just coming to the end of a fantastic glaucoma fellowship at Moorfields, during which Samad Ansari had been a colleague and friend, and soon to start as a consultant in Oxford where Rebecca Turner is Clinical Director, and with whom I have had a great working relationship and friendship over many years. They must have assumed that I had a lot of free time as they decided to spring on me that they would like me to write an article on ‘preparing to be a consultant’ with an imminent deadline.
As a result, these are my reflections on what I have done since being awarded my Certificate of Completion of Training rather than a complete guide, which will hopefully provide some useful tips for other people at a similar career stage.
Destressing over coffee with fellow colleagues at Moorfields Eye Hospital.
It’s daunting starting as a new consultant, especially at a time when NHS ophthalmology services are under so much pressure. One thing I have found though, which is a theme that runs through this article, is that there remains a great collaborative culture within ophthalmology. Clinicians are all busy, but I am sure that if you reach out to those who have been through the transition recently, or those who are more senior colleagues, everyone wants what is best for patients so they will be happy to share their knowledge and experience.
The value of early reflection
It takes such a long time to become a consultant that it can often feel like the destination, when in fact it’s just another (albeit important) step in what is hopefully a rewarding and fulfilling career. The training route forces us to cross many hurdles that ensure we can do the job so it’s important to remember you have been trained to do this. In addition to the clinical knowledge and skills we have had to obtain, reflection can often feel like an unnecessary addition but during fellowship training, I had to reflect deeply on my strengths and weaknesses and work hard on the latter to feel sufficiently prepared. In retrospect, I wish I had done this earlier as it’s always easier to keep doing more in the areas you are strong at whilst neglecting the areas that don’t come naturally but if anything, the latter needs greater attention.
Refining skills before Day 1
In the NHS, most ophthalmology posts come with a subspecialist interest – mine is glaucoma. Being a consultant however requires lots of different sills but most importantly, it’s paramount to have extensive clinical expertise in your subspecialty as that is where you will be the final decision-maker. For me this has meant a lot of time reading up on surgical techniques, the management of complications and going over guidelines. In busy clinics there simply isn’t time to look things up and you need to be able to draw this knowledge down and apply it quickly. This preperation has given me the confidence that I will be able to deal with queries from members of the multi-disciplinary team efficiently, which in turn frees up time to be able to see the complex or postoperative patients who I likely need to review.
Performing supervised glaucoma surgery during fellowship.
I think surgical numbers are important, and at least in glaucoma, there are published surveys and articles on surgical volume in different fellowships that give a rough starting point for the number and types of surgeries you should perform before starting fully independent practice. This is however very subjective and at least as important as the number is the quality of surgical mentorship, experience of a range of complexities, and experience with complex cases and revisions. I spent a lot of time asking mentors about how they approach different scenarios and then making notes and discussing these with other colleagues to give a framework of how to approach such situations.
Be proactive with administration
Something I have heard over the years is that when you start as a consultant “you will know what to do clinically but will struggle with the administrative side such as clinic profiles.” As a result, I was proactive and set up a meeting regarding clinic profiles. This did not seem to be too difficult and just related to the number and types of patients to be booked to each clinic. Having worked in glaucoma in different hospitals I was able to ask for a blend of the various setups I had seen but I think this could easily be achieved by asking advice from colleagues. Likewise, job planning was new to me but the system was easy to navigate, and the clinical lead was very helpful, so again this did not seem as great a challenge as it had sometimes been described to me!
There are however a lot of logins, badges, access to be sorted but none of this is complex and at least you know for once you won’t have to do it all again a year later (although this unfortunately may not hold true for mandatory training). Being proactive and getting a lot of this sorted before your first clinic is my only advice to make it as stress free as possible.
End of fellowship celebrations at Queen Victoria and Moorfields Eye Hospitals.
Leadership
Exposure to leadership responsibilities is something that is becoming more common as a trainee and I was fortunate to work as the National Medical Directors Clinical Fellow and then joint National Clinical Lead for Eyecare at NHS England, so have had some formal training and experience. This has however been a significant challenge as it requires making complex decisions, with imperfect information, and the problems are very unlikely to have an evidence base or guideline. In Oxford we are redesigning the glaucoma service with a big increase in virtual appointments among other changes, such as development of the multidisciplinary team. I was involved in this project as a fellow which has been helpful in allowing me to influence and shape the service I am now, along with other colleagues, responsible for. My advice would be to engage in service development early to try and improve efficiency, the team working environment, and experience for patients.
There is of course a balance, and I think it’s important not to take on too much when you first start. For example, I have an interest in using digital technology to improve eyecare, having been a medical director of a medical device company and a member of the college informatics committee, but agreed not to take on any digital roles for six months so as to be able to find my feet clinically first.
Preparing yourself and your environment
This may not be possible for everyone due to geographical constraints but I obtained an honorary contract prior to starting in order to attend some clinics and perform some surgeries with a consultant colleague, ensuring I was familiar with the setup and instruments before starting. I found this invaluable as it gave me an opportunity to speak to the scrub team, order particular instruments I wanted, and push for medical devices which I had been trained in during my fellowships and have now been approved for use in Oxford.
Avoiding burnout
For me, I felt it was important to have a holiday at the end of fellowship and spend some time with my family before starting. I also, however, wanted to have been operating recently before my first consultant list so took two weeks to relax in the Scilly Isles and Cornwall. Several experienced consultants have advised me to work very hard when at work but also space regular holidays where possible to allow me to switch off from work.
Kids trying to warm up after swimming in the Scillies.
Building your mentor network
Finding mentors, similarly to reflection, is something that I underestimated in the earlier stages of training but as I approached becoming a consultant, became key. I was fortunate during training to develop relationships with key opinion leaders with different subspecialist interests to mine who have been able to provide a lot of wisdom on how to develop your career. During my subspecialty training and fellowship, I worked with fantastic glaucoma surgeons at Oxford, The Queen Victoria Hospital and Moorfields who were generous in their training and it’s deeply reassuring to know that you have people on the end of the phone who can provide advice, or just talk through complex clinical situations. I think it’s important to have mentors both inside and outside of your subspecialty who can provide different perspectives on clinical work and your career more broadly.
Conclusion
Starting as a consultant can cause a lot of anxiety which is in some ways helpful as it forces meticulous preparation. It’s important to remember that we have one of the longest training programmes in the world and that we have passed a huge number of exams and assessments – we are ready to do this job.
There are a range of skills required but like with surgery, the key is preparation, reflection and refinement to get better at these. You are however not on your own and there will be lots of people willing to help and support you.
The end of a busy clinic with my consultant colleague, Rajen Tailor.
Hopefully this article contains some useful suggestions for those applying or due to start as a consultant soon. I will no doubt learn a lot over the first few years and look to provide an update in the future.
Declaration of competing interests: None declared.
