Respiratory medicineBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1628 (Published 07 April 2010) Cite this as: BMJ 2010;340:c1628
Andrea Collins talks you through everything you need to know about chest medicine
Chest medicine; pulmonology, respirology, and thoracic medicine; pulmonary medicine; or respiratory medicine—whatever you wish to call it, this specialty is as varied as the nomenclature used worldwide to describe it.
I was an old style medical senior house officer for two and a half years and so was fortunate enough to gain experience in almost all medical specialties. “Lucky you,” I hear many would be doctors and doctors in the era of the fast track system say. This experience was fantastic, but I was never clear where I was heading careerwise. I did all my exams for membership of the Royal College of Physicians; however, I wasn’t convinced general medicine was for me, and with the grass always being greener I embarked on a rotation in anaesthetics and the intensive care unit (ICU). This lasted 15 months, and I finally bowed out after slowly realising that medicine was the one for me.
I decided to apply to respiratory medicine (unfortunately through the dreaded medical training application service in August 2007) as this linked in well with my anaesthetic and ICU experience. I was also inspired by two joint intensive care unit/respiratory consultants who seemed to have an interesting work mix.
I had never really warmed to respiratory medicine as a senior house officer—so much chronic obstructive pulmonary disease, I thought; nothing you can do for them, always back in hospital a few months, weeks, or sometimes even days later; desperate lung cancer patients, such a poor prognosis; chest drains, not really sure what I am supposed to be checking for—swinging? Clamping? (box 1). The other medical senior house officer on my ward wanted a career in respiratory medicine, but is now a budding anaesthetic registrar.
Box 1: Likely responses from people who don’t know much about respiratory medicine
1) It’s all sputum, sputum, sputum
2) All they “do” is chronic obstructive pulmonary disease
3) You can’t do anything for patients with chronic obstructive pulmonary disease, lung cancer, pulmonary fibrosis, and so on
4) Respiratory disease is mostly self inflicted.
1) The microbiologists and physiotherapists deal with the sputum
2) Every specialty has its bread and butter aspects, and it is very rewarding if you actually know what to do
3) When did you train, 1935?
4) Great holistic attitude!
There is, however, much more to respiratory medicine. All specialties have their bread and butter aspects, which some love and some don’t. The main advice I was given as a junior was firstly, can you handle the bread and butter? Does asking patients 15 times a day about their rectal (PR) bleeding, chest pain, or breathlessness seem less mundane? Secondly, look around you—are the people in the specialty at all like you? Even if the training as a registrar may seem a bit tough (for example, in accident and emergency), do you actually know what the consultant job entails, because those four to five years as a registrar really do go quickly and you’re likely to be consultant for more than 30 years. Always remember there is much more to any specialty than you often see as a senior house officer looking after inpatients (box 2).
Box 2: Reasons to go into respiratory medicine
Enjoy a varied case mix (acute and chronic conditions with a wide age range)
Be part of a growing specialty
Be able to subspecialise or remain general
Be part of a rapidly growing area of research
Be involved with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) (skills that can be combined with a career in intensive care medicine)
Enjoy a variety of ward work, outpatients, and technical procedures
Be involved in palliation.
What is respiratory medicine?
In general respiratory doctors possess:
Excellent communication skills
A strong general medical knowledge base
The ability to work with other multidisciplinary team members
An aptitude for practical procedures
Ability to recognise multisystem diseases
An empathetic approach towards patients with chronic disorders
A willingness to accept new ideas and changes to established management regimens.
Respiratory medicine is an exciting, developing, and diverse specialty. There are many opportunities to develop a totally individualised career as a consultant (box 3). So many different respiratory conditions exist: some very common (asthma) and some rare (for example, Langerhans cell histiocytosis). There is, therefore, ample opportunity to subspecialise. Some respiratory units are highly specialised and provide regional services (for example, cystic fibrosis and lung transplant units); much of the workload in many units, especially in district general hospitals, is acute respiratory and general medicine.
Box 3: Life as a consultant
The work is very varied. Respiratory physicians spend two to three programmed activities (1 programmed activity=0.5 day) in clinics, which may be general or more specialist. Most respiratory physicians also look after inpatients and have ward rounds two to three times a week. A large part of a respiratory doctor’s role is education, from teaching community nurses and respiratory physiotherapists to teaching nurses and general practitioners working with patients who have lung cancer, cystic fibrosis, asthma, tuberculosis, and those who want to stop smoking. Procedures such as bronchoscopy lists take up other sessions. Most respiratory consultants continue to have an important role in the unselected acute medical take, and many tend to have a subspecialty interest.
Respiratory medicine continues to expand as a specialty as the burden of lung disease increases and as more treatment becomes available. This provides great opportunities for developing local services and encourages lifelong learning. “Developing new services such as difficult asthma clinics, sleep services, respiratory high dependency units, or tuberculosis contact tracing clinics is also a large and rewarding part of the job,” says Dr Burhan, respiratory consultant at the Royal Liverpool and Broadgreen University Hospital, Liverpool.
Integrated care (community respiratory medicine) is a growing specialty that allows consultants to work within the hospital trust and primary care trust. There are increasing opportunities to work as a consultant on a less than full time basis and to organise a job that focuses on your specific interests.
Entry into respiratory medicine
Entry is at specialty trainee (ST) year 3 level, after core medical training. Membership of the Royal College of Physicians will soon again be compulsory for entry into ST3. As with all jobs, the best way to get a training position is to show your commitment to the specialty. Obviously, where possible, experience of respiratory medicine during previous training is ideal, especially at ST1 or ST2 level. Respiratory medicine is one of the most competitive specialties, with around six to seven applicants per ST3 post.
Try to do at least one respiratory audit and ideally an abstract or poster (submitted to the British Thoracic Society, the European Respiratory Society, or the American Thoracic Society) while you are still a trainee. Be proactive and ask a friendly respiratory registrar or consultant if you can be involved in forthcoming projects. The British Thoracic Society’s website (www.brit-thoracic.org.uk) has many audit ideas within the audit tools section. Watch some bronchoscopies or thoracoscopies, or attend a lung cancer multidisciplinary team meeting or an outpatient clinic. Speak to local people to get advice, such as a respiratory consultant you are working with or have previously worked with, or the local training programme director.
This year respiratory medicine is not part of the national recruitment programme, allowing trainees more choice in their applications.
Training structure and exams
The training programme lasts five years, during which most registrars will rotate through subspecialties as well as general respiratory placements. All trainees will spend 60 days in ICU during their training.
There is excellent scope to subspecialise during training, for example in cystic fibrosis, transplants, pleural disease, sleep medicine, or integrated care. Technical skills are developed during training, such as chest drain insertion and bronchoscopy. Experience in newer techniques such as endobronchial ultrasound and thoracoscopy is also possible. Thoracic ultrasound (USS) is a key new development and all trainees from 2010 will be required to be competent in USS to level 1. Being able to perform “procedures” brings another interesting and practical edge to the job.
You will attend regular regional teaching sessions in respiratory and general medicine. Attendance of national meetings (British Thoracic Society) is compulsory. You are also expected and encouraged to attend international meetings, which are great opportunities to present posters and research internationally. Anaesthetic and further ICU experience is possible as out of programme experience. Research in respiratory medicine continues to increase and involvement is encouraged, which may include an MD or a PhD.
There is a lot of support for less than full time respiratory trainees. This is stated in the new curriculum, and the British Thoracic Society is also very supportive of this way of training. We are one of the most progressive specialties in this area. Currently, 45% of respiratory trainees are female.
All medical specialties now have a compulsory exam, the specialty certificate exam. It is advisable to sit this (at least a first attempt) in ST4. It costs £800 and currently takes place only once a year, in April/May. Little is known yet about this exam as the first sitting was in April 2009. At the end of the five year training period you will gain a certificate of completion of training in general medicine and respiratory medicine.
Life as a respiratory trainee
An approximate timetable would be two to three outpatient clinics a week, one bronchoscopy list on alternate weeks (which factor in on-call commitments and annual or study leave), one registrar led ward round, and two consultant ward rounds a week. The on-call commitment in general and acute medicine is much less than it used to be, thanks to the European Working Time Directive (box 4).
Box 4: Experiences of being a respiratory trainee
“I had dreaded being a medical registrar, thinking that the on calls were heavy and frequent, but it has mostly been better than I expected.”
—Dr Tack, University Hospital Aintree, Liverpool
“Much of the medical take (one third) is respiratory; therefore, I feel well prepared and knowledgeable within most of general medicine.”
—Dr Jordan, Liverpool Heart and Chest Hospital, Liverpool
I work full time and am currently an ST5 at the Royal Liverpool and Broadgreen University Hospital. I have already had experience in cystic fibrosis, bronchiectasis, sleep medicine, endobronchial ultrasound, and cancer, including spending a week with a thoracic oncologist. I am the specialist registrar representative for the British Thoracic Society’s specialty workforce committee and the flexible training representative. I have travelled to Berlin, Vienna, San Diego, York, sunny Bournemouth, and not so sunny Manchester for continuous professional development, and to present my work.
I really enjoy treating a variety of acutely ill patients such as those with life threatening asthma, respiratory failure, or pulmonary emboli. I also have the opportunity to care for patients with end stage chronic obstructive pulmonary disease or in the terminal phases of mesothelioma, all in the same week or even day. The workload is often quite high in respiratory medicine and most juniors would class it as one of their busiest jobs. But although the workload is high, it is manageable, and a good work-life balance is easily achievable.
As a registrar you continue to develop your own skills and teach others about diagnostic and therapeutic pleural aspiration; intercostal drain insertion; talc pleurodesis; bilevel positive airway pressure; and interpretation of chest radiographs and thoracic computed tomography scans. There is a great deal of multidisciplinary teamwork: we work closely with other specialties such as radiology, haematology, rheumatology, renal, infectious diseases, thoracic surgery, ICU, and cardiology.
Competing interests: None declared.