Intended for healthcare professionals

Feature Christmas 2011: Professional Matters

When is a “free” registrar in clinic not free?

BMJ 2011; 343 doi: (Published 20 December 2011) Cite this as: BMJ 2011;343:d7869
  1. Amrit S Lota, specialist trainee in cardiology,
  2. Charlotte H Manisty, specialist registrar in cardiology,
  3. Richard Sutton, emeritus professor of cardiology,
  4. Darrel P Francis, reader in clinical cardiology
  1. 1International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London W2 1LA, UK
  1. Correspondence to: A S Lota amrit.lota{at}


Objective To investigate whether using registrars (doctors undergoing higher specialist training, whose salary is reimbursed) rather than consultants in outpatient clinics saves money

Design Development of a formula calculating the economic breakeven point and application to retrospective audit data from 273 outpatient consultations.

Setting General cardiology outpatient clinic in a secondary and tertiary referral NHS hospital.

Outcomes Difference in probability of a registrar and a consultant making a diagnostic decision that completes a clinical episode. Use of UK costings for consultant salaries and outpatient attendances to determine the economic breakeven point.

Results The formula showed that if a registrar’s episode completing probability is 12 percentage points lower than that of a consultant, then using a registrar costs the hospital more. Real life data showed that episode completion probabilities are 43 percentage points lower for registrars than for consultants (26% versus 69%, 95% CI 32% to 54%, P<0.0001).

Conclusion It is wrong to assume that external reimbursement of registrar salaries makes them a money saving option for staffing clinics. The apparent service role of a registrar can be a disservice.


  • Contributors: RS recognised that trusts erroneously assume a registrar is financially beneficial. DPF (guarantor) developed the three pronged explanation for trusts, ASL derived the formula and conducted the audit, CHM critically reviewed and edited the manuscript.

  • Competing interests: All authors have completed the ICJME unified declaration form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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