Learning to say NO
Dear Friend,
I was tempted to skip this week’s newsletter, as I’m still on holiday in the United States. With the eight-hour time difference, when this lands in your inbox on Sunday evening, it’s only 10 a.m. here. But consistency is the key to any goal, and since setting myself the challenge of writing a weekly newsletter back in January 2024, I’ve managed to stick with it so far.
As I prepare to begin my oncology registrar post in September, I’ve already had supervisors approach me with opportunities to get involved in audits, research, teaching, and more. The possibilities seem endless. In oncology, there’s also an expectation that you’ll take part in at least a few of these activities—especially with competition for training places growing year by year. Building a strong portfolio early on is becoming more and more important.
The same applies to medical students beginning a new academic year and newly graduated foundation doctors. The e-portfolio requires evidence of audits, research, teaching, and other achievements.
When I started as an FY1, I threw myself into everything — taking on an audit in my first rotation while also beginning my AFP research. By November, I was already burnt out. So this week, I want to share some thoughts on the importance of knowing when to say “no”—and recognising when your plate is already full.
Don’t underestimate the job
It’s almost paradoxical: when it comes to specialty applications, the process is judged almost entirely on your portfolio and interview. How you actually perform on the wards matters very little, provided you’ve passed your ARCP. Yet every time you start a new clinical rotation, it takes at least a month to find your feet—getting to know your consultants, understanding your responsibilities, and learning the ropes. If you’re an FY1, I’d say it takes twice as long.
That’s why I recommend holding off on projects during your first rotation. Give yourself 3–4 months to settle in and reach a stage where the day-to-day work feels automatic. Only then should you start taking on audits, research, or teaching commitments.
Don’t double up
A strong portfolio is about quality as well as quantity. Three audits aren’t as valuable as one audit, one teaching project, and one publication. Aim to cover a range of domains rather than repeating the same type of project. If you’re already working on an audit and another one comes your way, it’s usually best to pass. Some doctors try to compensate for a lack of publications by doing multiple audits—that doesn’t really work.
Arrange your projects around on-calls and exams
While portfolios matter, for many specialties exams carry far more weight. For example, you can’t progress to medical registrar without completing the MRCP, and entry into GP or psychiatry is based solely on the MSRA—regardless of portfolio. Once you’ve chosen your career path, focus your energy on the highest-value activities. If exams are looming, resist the temptation to take on extra projects that could compromise your performance.
Summary
I wish the system allowed doctors and students to pursue projects out of genuine interest rather than to tick boxes. But the reality is that balance is key: doing too little will hold you back, while doing too much risks burnout. Remember, it’s only August—there’s plenty of time to build your portfolio without overloading yourself.
As for me, I always take August a bit lighter since it’s my birthday month.
Drug of the week
Tacrolimus
Tacrolimus (also known as FK-506) is a powerful immunosuppressant medication primarily used to prevent organ transplant rejection.
It is also used in a topical form for treating severe skin conditions like atopic dermatitis.
Tacrolimus is classified as a calcineurin inhibitor and macrolide drug.
It works by suppressing the body’s immune system, specifically by disrupting the transcription of IL-2 and other cytokines within T lymphocytes, thereby interfering with T-cell activation, proliferation, and differentiation.
Side effects can be severe and include infection, cardiac damage, hypertension, blurred vision, liver and kidney problems (tacrolimus nephrotoxicity).
A Brain Teaser
A 49-year-old man comes to see you for advice on smoking cessation. He is interested in trying an electronic cigarette to help him stop smoking. You recently read about a trial comparing electronic cigarettes with nicotine replacement therapy for smoking cessation. Patients attending appointments in primary care were alternately allocated to the intervention group and control group.
This may put the study at risk of what kind of bias?
A: Attrition bias
B: Perfomance bias
C: Randomisation bias
D: Selection bias
E: Selective reporting bias
Answers
The answer is D – selection bias.
The correct answer is Selection bias. Selection bias refers to systematic differences in the baseline characteristics of the groups being compared. Successful randomisation preventions selection bias, but if randomisation is not done robustly selection bias can occur. For example, if alternate patients attending a primary care practice where patients were recruited into a randomised controlled trial (RCT) were allocated to the intervention (electronic cigarettes) and control (nicotine replacement therapy) clinic staff may (intentionally or unintentionally) book patients in such a way that those they consider to have more chance of benefiting from the intervention (e.g. those who are heavier smokers) enter the intervention group leading to systematic baseline differences.
Attrition bias is incorrect as this refers to systematic differences between groups in withdrawals from a study.
Performance bias is incorrect as this refers to systematic differences between groups in the care provided or in exposure to factors other than the interventions of interest. Effective blinding of study participants and personnel can prevent performance bias.
Randomisation bias is incorrect. The correct term for the type of bias caused by systematic differences in baseline characteristics due to a lack of robust randomisation is selection bias.
Selective reporting bias is incorrect as this is where within a study those analyses with statistically significant differences between groups are more likely to be reported than non-significant differences.
