Supporting unaccredited registrars as valued members of the surgical team

Unaccredited registrars are positioned in a precarious situation. In Australia, an ‘unaccredited registrar’ is a junior doctor who has completed their internship and works in a hospital setting as a medical officer, often for several years. Unlike their accredited counterparts, they do not participate in a speciality training program, however, they undertake many of the responsibilities typically associated with an accredited registrar position. Hospitals depend on unaccredited registrars to fulfil their service obligations and they play an essential role in staffing clinics, assisting with surgical procedures and fulfilling on-call rosters. Clinical experience as an unaccredited registrar in a surgical specialty is a prerequisite for selection into surgical training programs and referee reports authored by consultant surgeons are a requirement for applications into these programs.¹ The selection process is notably competitive with a significantly higher number of applicants than available positions.

Concerns about unaccredited registrars have increased over the past few years. Accreditation standards for hospital training posts in surgical education² require that surgical units:

1. implement policies and processes for trainees to report breaches in working hours

2. adopt fatigue minimisation practices if fatigue is identified

3. accommodate roster requests to enable work–life balance

4. respond to trainee feedback

5. offer trainees access to supervision, including a minimum number of supervised clinics and theatre sessions

6. provide a range and volume of clinical experience to facilitate their development

7. coordinate a schedule of learning opportunities.

However, unaccredited registrars lack the protection of these accreditation standards or any national legislation that limits the maximum number of working hours per week. They depend entirely on the generosity and fairness of their superiors to maintain a decent work environment, let alone foster career development.

Australian research shows that junior doctors experience high levels of psychological distress.³ Stressors intrinsic to the job include a heavy workload and long hours, which disrupt normal eating and sleeping routines. Additionally, there are contextual stressors, such as: lack of role clarity; challenging relationships with colleagues, including a lack of appreciation and respect from senior doctors; and a perceived lack of job security.⁴ A recent study found that one in four junior doctors work hours that double their risk of common mental health problems and suicidal ideation.⁵ This is particularly concerning as a large systematic review and meta-analysis indicated that the rate ratio of male physician suicide stands at 1.05, and for female physicians it is significantly higher at 1.76. The suicide rate ratio for male physicians compared to other professions is 1.81.⁶

In 2020, NSW Health initiated a review of unaccredited training positions and published a discussion paper with draft recommendations.⁷ However, it appears that little has been done to implement these recommendations. Broader change is needed in relation to medical workforce planning and the oversight of prevocational doctors.

Unaccredited registrars are vital members of the surgical team. A positive culture of inclusiveness, the enablement of juniors and supportive teamwork fosters psychological safety⁸ and encourages ‘speaking up’, leading to enhanced patient safety.⁹ Surgeons who work in hospitals that employ unaccredited registrars can help to improve the day-to-day work environment for junior colleagues. The following suggestions apply the values and principles of the Australian Society of Plastic Surgeons ethical framework.¹⁰

Contribute to orientation

In 2024, only 63 per cent of prevocational and unaccredited registrars had a formal orientation to their setting or rotation.¹¹

• Inquire whether new registrars have received the information they need to work effectively.

• Provide practical information that may help them navigate the first few weeks in the new environment.

• Facilitate the development of an orientation manual for unaccredited registrars, if one does not exist in the department.

• Be approachable to answer any questions about departmental norms that may not be addressed in written documentation.

Be explicit about expectations

Setting clear expectations, being inclusive, and role-modelling behaviours and actions that registrars should emulate, creates a culture of trust and psychological safety.¹²

• Build rapport first, including gaining some knowledge about their previous experience, what they are confident with and when they might need more direct supervision.

• Outline expectations early.

• Encourage registrars to ask for clarification or help when needed.

• Signal that feedback will be provided on their performance with the intention that they will learn and improve their ability to perform clinical tasks. Registrars are more likely to be receptive to feedback when it is presented as a learning opportunity, especially when you have an established rapport.¹³

Demonstrate respect and patience

Unaccredited registrars depend on referee reports from supervising surgeons for selection into surgical training. This creates a power imbalance that may leave this group vulnerable to work-related stress and workplace bullying and harassment.¹⁴ They might agree to take on an unreasonably high workload to impress others and/or secure ongoing employment or a training position.

• Maintain professional boundaries at all times.

• Be mindful of the power imbalance between you and the registrar and ensure that this is not exploited (unintentionally or otherwise).

• Extend the same courtesies that you would to other colleagues when communicating about clinical work or delegating duties.

• Inquire about their current workload and priorities when requesting tasks be completed urgently.

• Avoid miscommunication by routinely checking the person’s understanding and encouraging questions to clarify any uncertainty.

Provide performance feedback

Constructive feedback helps learners change their behaviour and encourages them to practice independently.¹⁵

• Try leading with ‘May I give you some feedback…’ before suggesting how they could improve.

• Approach feedback as a dialogue, rather than a one-way information transfer, as this supports acceptance of the feedback provided.¹⁶

• Reinforce positive behaviours by letting them know what they are doing well.

• Before you observe their work, ask the registrar if there is anything that they would like feedback on.

Maintain professionalism when there are performance concerns

Professionalism is an attribute that can be taught by example.¹⁷

• Acknowledge role-modelling as a powerful teaching tool.

• Contribute to the development of a generation of surgeons that demonstrates respect by proactively raising concerns and working with others to address them.

• Recognise issues that lead to frustration and address them in a timely manner, before they progress to issues that incite anger.

• Organise a time to discuss any concerns with the registrar, in a private setting, preferably with a suitable colleague who can witness the conversation.

• Focus comments on observations of the registrar’s behaviour,¹⁸ which they can demonstrate change in, rather than on personality attributes, and highlight any discrepancy between current behaviour and the expectations that have been outlined.

• Be specific about the consequences if their behaviour does not change to meet expectations.

Recommend learning resources and become a mentor

Unaccredited registrars have similar responsibilities to specialist trainees, yet they do not receive structured education opportunities or access to formal mentoring initiatives. However, unofficial mentorship programs can still have significant benefits for both mentor and mentee.¹⁹

• Assist enthusiastic registrars by offering guidance on career pathways in surgery—the JDocs website²⁰ outlines a framework detailing essential clinical skills that should be attained by doctors in their early post-graduate years.

• Hone your communication and leadership skills by taking on the role of a mentor for a prevocational doctor—you can find resources for surgical mentors on the JDocs website as well.²¹

• Bolster the clinical and non-clinical learning of registrars by allowing them to draw on your experience.

Advocate for fair working conditions

Doctors report higher rates of burnout than the general population, with almost half of Australian junior doctors reporting emotional exhaustion.³ Organisation-directed interventions are more likely to lead to reductions in burnout than physician-directed interventions at an individual level.²²

• Advocate for reasonable work hours, fair pay and registrar input into work schedules.

• Implement fair workload management strategies.

• Be mindful of how you may contribute to a registrar’s already long working hours by making ‘last minute’ or ‘before you go’ requests which are not necessarily urgent.

• Recognise the importance of rostered time away from work and adequate leave to overall health and wellbeing.

Recognise high levels of psychological distress and offer support

Stigma reduces a doctor’s capacity to recognise their health needs and entrenched stigma toward mental illness is one of the main barriers to disclosure and help-seeking for younger practitioners.²³

• Extend compassion toward the struggles of junior colleagues and encourage the use of professional services when needed.

• Be willing to discuss illness—disclosure is challenging in a medical culture that rewards perfectionism and lauds heroism,²⁴ but sharing real stories may prevent illness being equated with failing and support doctors to access health care.²⁵

• Suggest using hospital employee assistance programs (EAPs), or similar.

• Recommend resources designed specifically for health professionals:

  • provide details of doctors’ health services²⁶—each state and territory has independent, free and confidential health advisory services staffed with doctors trained in doctors’ health.

  • the Black Dog Institute’s TEN—the Essential Network for Health Professionals²⁷ is an e-hub for health professionals which includes evidence-based tools and resources, including digital programs for navigating burnout and maintaining good mental health.

• Invest in activities that will support your own physical and mental health, and model this behaviour to junior colleagues.

In the future, an unaccredited registrar may become a plastic and reconstructive surgical colleague or be responsible for the care of a family member.

Respecting and supporting unaccredited registrars, and encouraging others to do similarly, facilitates psychological safety. In turn, a psychologically safe work environment can improve work satisfaction, foster learning, and maximise the performance of individuals, teams and organisations.²⁸

Disclosure

The author works as a consultant for the Australian Society of Plastic Surgeons and was paid to research this editorial.

Revised: February 5, 2025 AEST