Specialty career profile: respiratory medicine

At the beginning of my hospital medicine career I really enjoyed all aspects of the acute medical specialties and had no strong preference. However I then worked with a chest physician in Banbury who by example showed me how this specialty could be so rewarding, as it encompassed such a wide variety of clinical problems. It was apparent to me that a good respiratory physician would and should also be good at general medicine, and that most are still heavily involved in the acute medical on call. I recall a senior in Oxford telling me that respiratory medicine was like being a detective when investigating the abnormalities seen on chest X-rays, and that a challenge was to find the cause of the shadowing.

I qualified in 1990 and spent 1 year as a house officer (6 months each in surgery and medicine), followed by 6 months as an SHO in Accident and Emergency, also passing MRCP part 1. I then took 6 months off to travel to India and Thailand before returning to an SHO rotation for 2 years in Banbury and Oxford, during which I passed the membership exam. I then applied for higher specialty training in respiratory medicine.

Requirements for entry into respiratory medicine are fairly similar now, and all trainees would be expected to have completed core medical training (CMT) or equivalent and to have achieved the MRCP examinations including PACES. Part 1 MRCP is an essential requirement for application to specialty training year three (ST3), but full MRCP is necessary to actually take up an ST3 post in the medical specialties.

Doing a CMT rotation that includes respiratory medicine is desirable although not everyone will always get this opportunity. Making sure you are doing as much GIM as possible is also essential as so much of our work is seeing and treating people admitted with respiratory disorders through the on-call medical take. It also helps if, during CMT, you can attend some clinics, learn to do some relevant practical procedures such as chest drain insertion and attend X-ray meetings and perhaps some lung cancer multi-disciplinary teams (MDTs) in order to familiarise yourself with radiology interpretation and team working which are such a major part of our specialty.

After obtaining my MRCP, I was appointed to a registrar rotation commencing in High Wycombe for 2 years and then Oxford for a further year. During this period the Calman training programme was introduced and I was fortunate enough to be converted into a 5 year programme. I went onto do further clinical training in the John Radcliffe Hospital, including more general medicine and also 6 months in intensive care. Following this I was a research registrar and helped to set-up a large multicentre trial in the management of pleural infection before becoming a consultant in Reading in 2000.

Yes, the medical inpatient load involves a large number of patients with a chest or breathing problem, or abnormal X-ray or scan. We are asked to see patients who are under the care of the intensive care unit, surgical teams, haematology and oncology, cardiology, neurology and many more.

For our outpatients we work especially closely to cardiologists, rheumatologists, radiologists, pathologists, cardio-thoracic surgeons and oncologists. There is now an increasing burden of obesity related illnesses affecting the respiratory system, so we are now working closer than ever with the anaesthetists, surgeons and endocrinology teams for these patients as well.

In short, respiratory medicine is central to the running of both in-patient and out-patient medical services in every hospital in the country.

Respiratory medicine involves contact with people from all backgrounds, ethnicities and social classes, and all ages from young to elderly. It often involves looking after the most ill patients in the hospital and seeing many chronic and incurable conditions both as out-patients and inpatients. After many years it is very satisfying to provide continuity to the care of some patients, even if their medical condition cannot be cured and may be declining.

There is also constant interaction with all other healthcare groups, in the wards, clinics, laboratory and meetings which is constantly enjoyable and stimulating. Many respiratory specialists find that they have the skills to be clinical leaders during their careers and most enjoy teaching.

We have to make difficult decisions about end of life care in patients with terminal or chronic disease, and at other times decisions about treatments with potential adverse effects in the out-patient clinics. We frequently use our ability to work in teams to aid some of the more difficult decisions and to share our experiences of previous treatment outcomes.

Most people, once having achieved consultant status, spend some years learning to deal with all the things you don’t learn as a trainee. Many, like me, also get involved in clinical director roles and educational roles. Personally I think that the future in medicine is education.

My typical day is from 8am to 6-7pm. I do an on call about once every 2 weeks and am expected to stay in hospital until about 8–9pm, remaining on call from home overnight. I also work about eight weekends per year.

There are also several large international respiratory meetings each year which you can attend. Some are able to organise overseas work as part of their training as out-of-programme experience and many consultants later in their careers will lecture and teach overseas.

Yes, always. Respiratory medicine is so fundamental to the acute hospital that we are constantly teaching both informally on the job, and formally to students, trainees of all levels and also allied healthcare workers and GPs.

Research is encouraged as part of the curriculum for respiratory medicine and many existing consultants have done periods of research including higher degrees such as an MD or PhD during their registrar training. Several of my current trainees have done or are completing research projects and have produced papers in peer-reviewed journals. There is also an academic clinical fellowship (ACF) programme for those who intend a more academic pathway usually at a ‘registrar’ level and occasionally at a CMT level in some regions. Research is both scientific/molecular and clinical, and there are many well established research networks in respiratory medicine within the UK.

Yes, much of our work is as a multidisciplinary team, working with specialist nurses, ward nurses, physiotherapists, occupational therapists, physiologists, radiographers and pharmacists.

Apart from my main work I have been clinical director for medicine, training programme director for respiratory medicine for the Oxford Deanery and a member of the specialist advisory committee (SAC) of the JRCPTB. I also provide support to the local asbestos support group and have over 40 publications including some book chapters.

All the generic skills of any good doctor which include excellent communication skills, empathy, patience, sound clinical decision-making, good time-management and prioritisation, working effectively in a team and being able to delegate safely. It also helps to have an inquisitive mind.

The most important qualities I want to see in my junior doctors are interest and commitment to the specialty. It is refreshing when someone who has genuine commitment appears at work or in an interview. This is often apparent when someone has demonstrated they have read guidelines or some articles in respiratory medicine and has done projects such as audit in one of these areas.

If possible go and talk to and work with a respiratory physician for a few hours or days. Watch how they work and interact with people and the types of patients and clinical scenarios they have to manage. Try and go to a clinic or a procedures list and attend an X-ray meeting or MDT. If you find you are enjoying the varied workload and potential to also do procedures such as bronchoscopy then respiratory medicine might be for you.