VARIETY is a core part of respiratory medicine where specialists deal with more than 30 different acute and chronic conditions across a wide age range.
This diverse field covers a broad spectrum of disorders, some very common and some rare. They range from inherited conditions like cystic fibrosis, infective conditions like pneumonia and empyema, as well as others such as vasculitis, lung cancer, and chronic obstructive pulmonary disease (COPD).
Respiratory conditions are among the UK’s biggest causes of mortality, accounting for almost a third of all acute admissions and costing the NHS billions of pounds every year. In addition to acute care, many also require lifelong outpatient treatment for chronic disorders, giving specialists the chance to build long-term therapeutic relationships.
Demand for treatment seems unlikely to decrease for the foreseeable future – indeed areas such as lung cancer and sleep services are continuing to expand to meet growing needs. Add to this the increasing opportunities in research, and it is fair to say specialists in this field will never be short of a challenge.
Entry and training
The first step to enter specialist training in respiratory medicine is to complete two years of core medical training (CMT or Acute Care Common Stem (ACCS)) and to gain membership of the Royal College of Physicians (MRCP) or pass a recognised equivalent examination. Higher specialty training then begins at ST3 level, by which point the British Thoracic Society (BTS) recommend doctors have at least one period on a unit with a specialty respiratory interest. The BTS says: “Ward-based practical skills can be developed during this time and there is sometimes an opportunity to begin to learn bronchoscopy and pleural USS. This may help crystallise your decision to pursue a career in the speciality.”
Commitment to the specialty can be further demonstrated by gaining research experience, often carried out after entering specialty training.
Core/specialty training generally lasts six years in total and covers both general and respiratory medicine. There are options to train less than full time (LTFT) which is commonly 60 per cent whole time equivalent. Many doctors choose to dual qualify and gain an additional certificate of completion of training (CCT) in general internal medicine which usually adds one extra year to specialty training. Those interested in this pathway must complete an officially designated dual CCT programme.
The General Medical Council’s Specialty training curriculum for respiratory medicine contains detailed information about the various clinical and practical competencies expected of doctors. This includes inpatient and outpatient training and experience; knowledge of respiratory anatomy, physiology, pathology, microbiology and pharmacology; intensive care medicine; and radiological and imaging techniques.
It lists a number of “essential areas of training” for which doctors may need to attend an approved course, such as those offered by the BTS.
Desirable qualities for a respiratory specialist include an aptitude for practical procedures, an empathetic approach to patients with chronic disorders, and the ability to stay calm and make decisions in an emergency situation.
The BTS, said to be one of the most active societies in the UK with a reputation for being “friendly and progressive”, also welcomes enquiries from doctors who are considering a career in the specialty.
Respiratory physicians are almost exclusively hospital based, with a large part of their work providing acute inpatient care. At least twice a week they can expect to lead ward rounds with junior medical staff, ward nursing staff, and respiratory physiotherapists.
A career guide from the BTS describes how, as around one third of all acute medical admissions are due to respiratory problems, many respiratory physicians also choose to have a general medical commitment and participate in “medical takes”, which often entails looking after patients whose primary problem is not necessarily a respiratory disorder.
It adds that most respiratory physicians supervise non-invasive ventilation in the support of patients with acute respiratory failure in the high dependency unit environment, and many have sessions helping to run intensive care services and expertise in the management of adult respiratory distress syndrome.
In some regions, highly specialised respiratory units have been set up to offer complex care for issues such as lung transplant, sleep related medical problems and adult cystic fibrosis. For most units the care largely focuses on acute respiratory and general medicine.
As with many specialists, working within a multidisciplinary team is a prominent part of the respiratory physician’s role. They have close relations with specialist respiratory nurses, community respiratory teams, respiratory physiotherapists and specialist respiratory technicians as well as other medical staff. There are also close links between the specialty and both radiology and thoracic surgery.
In addition to clinical and research skills, specialists have considerable technical abilities. Common procedures include bronchoscopy (both diagnostic and, increasingly, interventional); pleural procedures including pleural biopsy and chest drain insertion; medical thoracoscopy for the more invasive investigation of pleural effusion; and non-invasive ventilation. They are also responsible for providing the non-invasive ventilation services as well as the sleep services in most hospitals.
Respiratory specialists have considerable expertise in cardiopulmonary physiology and run lung function laboratories in most hospitals for the interpretation of complex lung function testing, a cornerstone of respiratory diagnosis. In the outpatient setting, respiratory physicians run the services for lung cancer and tuberculosis (TB) in most trusts.
There are great opportunities to subspecialise or remain general. While there are no formally recognised sub specialties, there are a number of important “special interest” areas: adult cystic fibrosis, pulmonary hypertension, lung transplantation, domiciliary non-invasive ventilation, lung cancer, sleep breathing disorders and TB.
The specialty has a strong future. It is increasingly recognised that respiratory physicians are best placed to manage asthma, while the number of adult cystic fibrosis and COPD patients requiring specialist care continues to rise. Technical skills are also increasing, with expansions in interventional bronchoscopy and more widespread use of medical thoracoscopy.
With such a diverse range of pathways to follow, respiratory medicine promises a challenging and ever-changing career for doctors.
• The British Thoracic Society – A career in respiratory medicine