In our latest RCP next generation campaign blog, the winner of our 2025 ACT abstract competition, Dr Dominic Mears, shares how he, along with colleagues Dr Ming-May Chung and Dr Emily Robinson introduced an Acting Up scheme at Worcestershire Acute Hospitals NHS Trust (WAHT) to give doctors training in internal medicine real-world experience of the registrar role.
The leap to medical registrar is one of the most daunting transitions in a doctor’s career. It’s a step that many resident doctors doing internal medicine training (IMT) approach with anxiety, and understandably so. Historically, this transition has been abrupt, with few opportunities for resident doctors to act up in the role under supervision. When acting up did happen, it was often informal, unstructured, and lacked meaningful feedback.
At Worcestershire Acute Hospitals NHS Trust (WAHT), we wanted to change that. Our goal was to create a structured, supportive environment where second-year IMT doctors could experience the registrar role in a real-world setting, but with the safety net of supervision. We introduced a formal Acting Up scheme, giving resident doctors a 5-day block of normal working days to hold the on-call medical registrar bleep under the direct supervision of the duty registrar.
Getting started
As a team of associate and college tutors, we began by drafting a Standard Operating Procedure (SOP) to clearly outline expectations for both resident doctors and supervisors. This document became the backbone of the scheme, ensuring consistency and clarity. We then worked closely with key stakeholders, including the medical staffing team, chief registrar, and medical directorate to get the SOP approved and schedule the acting up weeks.
As with any project, there were lessons learned from the get-go. After our first trial, we realised that having only one crash bleep was problematic; the resident doctor and supervisor weren’t always notified simultaneously during emergencies. We quickly updated the SOP to require two crash bleeps, ensuring both parties are alerted at the same time.
Another key lesson was around clinical accountability. It’s vital that everyone understands the supervising registrar remains responsible for decisions made during the acting up period. We now emphasise this point clearly and ensure resident doctors introduce themselves as ‘medical registrar acting up’ when communicating with colleagues, to avoid any confusion about their role or level of seniority.
What went well
The feedback was overwhelmingly positive. Every resident doctor who participated said they’d recommend the scheme, and every supervisor agreed to take part again.
Resident doctors had the chance to lead emergency calls, clerk patients in emergency department resus, and manage junior colleagues during the acute medical take. One of the scheme’s greatest strengths was that resident doctors were supernumerary, they weren’t counted in the staffing numbers, which allowed for immersive learning without compromising patient safety.
Personally, I found it incredibly rewarding to see resident doctors grow in confidence and capability over the course of just 5 days. The scheme has now become a permanent part of the IMT programme at WAHT, and we’re excited to see how it continues to shape future registrars.
Looking ahead
We’re keen to expand the scheme to include out-of-hours shifts, such as evenings and nights. However, this presents contractual challenges. If resident doctors are working outside their normal hours, they need to be paid, which complicates things. One idea we’re exploring is adding a voluntary evening shift to the 5-day block, but this would depend on resident doctor willingness and feasibility.
We propose that a similar scheme should be incorporated into all IMT posts nationally so that resident doctors are optimally prepared for the medical registrar role.
‘With the NHS’s strong emphasis on consultant-led care, we must invest in high-quality training for resident doctors at every level so that they can develop into adept consultants and leaders of the future.’
Top tips: Acting Up with confidence - Lessons from Worcestershire Acute Hospitals NHS Trust
- Start with structure – draft a clear SOP outlining resident doctor and supervisor expectations to ensure consistency.
- Engage stakeholders early – involve medical staffing, chief registrars and medical directorate to secure buy-in and scheduling support.
- Double the crash bleeps – make sure both resident doctor and supervisor are alerted simultaneously in emergencies.
- Clarify accountability – emphasise that the supervising registrar remains clinically responsible throughout, and ensure resident doctors introduce themselves as ‘acting up’ registrars.
- Keep it supernumerary – avoid counting acting up shifts in the rota so learning is immersive but patient safety is protected.
- Gather and act on feedback – build in structured reflection to refine the scheme and embed it sustainably.
- Think ahead – explore opportunities for out-of-hours experience but be mindful of contractual and payment challenges.
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Dr Dominic Mears
IMT doctor
