Chest Physician?

INTRODUCTION

Respiratory Medicine is an extremely rewarding career choice for any junior doctor seeking a future in frontline medicine. The prospective trainee can look forward to experience in a broad and constantly evolving field of medicine closely linked to many other specialities. Hence a chest Physician is the embodiment of a team player; linking with oncology, radiology, intensive care, cardiology and the emergency medicine departments. Current developments in Ambulatory and Community linked services dovetail a service with a strong history of chronic disease management.

Chronic Obstructive Pulmonary Disease, Asthma and Lung Cancer represent a sizeable component of the Respiratory Team workload. However more than 30% of a General Medical acute Take-in has a primary respiratory diagnosis. Lung infections, Tuberculosis, Cystic Fibrosis & Bronchiectasis are another significant cohort of patients requiring multiprofessional training and a specialized skillset.

The trainee will specifically experience excellent structured training in the management of pleural disease and Acute Respiratory failure, and long term home ventilation. Recent developments in Diffuse Parenchymal Lung disease are revolutionising both early diagnosis and treatment options. Occupational lung disease offers the trainee a chance to explore potential cause & effect, whilst Sleep Medicine is a burgeoning subspeciality in itself. Physiology and Exercise Testing are the bread & butter investigations used in conjunction with Radiology to enhance this broad spectrum of fascinating conditions.

THE JOBBING CHEST PHYSICIAN

The exposure to acute respiratory patients can seem daunting, but with Thoracic Ultrasound & aspiration as well as Non-invasive Ventilation as part of a trainees treatment armamentarium it is an extremely rewarding service. Close links with Intensive Care & Emergency Medicine Clinicians allow the trainee to experience and learn from a range of emergency conditions to develop their skillset.

Chronic disease management is often reflected in a busy outpatient service with links into Community Respiratory Teams and Ambulatory pathways. The average Respiratory Physician usually has two outpatient clinics per week, with an additional session for diagnostic bronchoscopy and Endobronchial Ultrasound. The Respiratory Physician is the cornerstone of any lung cancer diagnostic service with weekly fast-track clinic slots, lung cancer Multidisciplinary Team meetings and close networking with Thoracic surgery and Oncology teams. There is an obvious need for some experience end of life issues and palliative care experience.

On call is a must with Respiratory Medicine representing one of the main GIM specialties. Night cover and weekend triage are likely to be part of your future career.

Transition clinics are well established for CF but developing for other services in conjunction with our paediatric colleagues. Even smaller Respiratory units encourage subspecialty interests and clinics, with Respiratory Physicians having a key role in audit, research and teaching interests.

TRAINING PROGRAM

Entry into the training program requires 24 months of CMT (or the new IMT training) following Foundation Training. Attaining MRCP allows the prospective candidate to enter competitive interviews for IMT & Specialty Training. The successful applicant enters at least 5 years of training with flexible/part-time training encouraged and supported.

All trainees are enrolled in dual training in Respiratory & GIM with the ultimate aim of attaining CCT in both. A minority opt to dual train in ICM/Respiratory instead, triple accreditation is no longer possible.

The trainee would normally spend the first few years obtaining the requisite skills in Thoracic Ultrasound (TUS) & pleurocentesis/pleural interventions: ultrasound competencies are required (Level 1 essential). New TUS Training standards are being released this year in conjunction with the British Thoracic Society. Diagnostic Bronchoscopy & EBUS training is required with competence based assessments. Parallel trainee exposure to the Acute General Medical Take-in & management of a wide cohort of inpatients is also expected as part of the training process.

Formal modular training is arranged in a series of Regional Respiratory Training days (minimum of 70% attendance) taking the form of lectures and tutorials by senior clinicians based on the Respiratory syllabus.

Ongoing assessment throughout the training period is competence based using WPBAs. Annual GIM & Respiratory progress is assessed with the Training Program Director & Local Deanery using the ARCP process. The extensive respiratory curriculum is available at http:/www.jrcptb.org.uk.

The Specialty Certificate Exam (SCE) is required before CCT can be awarded. Trainees are encouraged to sit the exam in ST5-ST7. Further details of the examination are available through mrcpuk.org.

In Northern Ireland trainees will tend to rotate on a 6 monthly basis through approved NIMDTA posts to maximise the training experience. This must include at least 60 days Intensive Care Medicine Training.

Teaching qualifications are encouraged through QUB Department of Education (Postgraduate Diploma or Masters). Senior Trainees are frequently supported to opt Out of Program (OOP) by way of a fellowship in a centre of excellence – allowing enhanced subspecialty experience; subject to JRCPTB approval if the time out is to be counted towards CCT.

NI Respiratory Medicine has an excellent Research background, with trainees encouraged to opt for a 2-3 year period of full-time research leading to a higher degree (MD or PhD).

THE FUTURE OF RESPIRATORY TRAINING

The speciality continues to evolve apace and training reflects that. The imminent advances in early lung cancer diagnosis and lung cancer screening are likely to be well embedded within the next decade. The rapid developments in endobronchial procedures and treatments will see more training possibilities in EBUS, stenting, endobronchial valves and even thermoplasty.

Diffuse Parenchymal Lung Disease is now a subspecialty in its own right with Multidisciplinary meetings and new novel effective treatments options.

Transplantation Medicine is now a closely affiliated speciality which all trainees will be expected to have a degree of experience in. We shouldn’t forget Health Promotion and Teenage Transition clinics also.

So, would I consider an alternative specialty if I could wind the clock back? Absolutely not, I can wholeheartedly recommend this fascinating and diverse medical specialty to any budding clinicans.