Medical Specialties - Respiratory Medicine (26 Jun 2024)

SPEAKER_00 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. Natalie, welcome. Hi, thank you for having me. Thank you for coming. So on this podcast, we tend to want to either encourage people that might be thinking about going into a specific specialty as to why they should, or provide a bit of information to people who perhaps haven't chosen their specialty, what your specialty involves. So why don't we start with the very simple question of why did you go into respiratory medicine? So I'd done it respiratory a couple of times.

SPEAKER_01 1:22

So I'd enjoyed it at medical school and I chose to do it as part of my core medical training back when core medical training was a thing. So for IMT for people that are doing that now. And I got really involved with it when I was doing my core medical training. So I loved procedure side and made sure that I got really involved with those and had a go ultrasound and got really inspired at an SHO level in what was involved. So then sort of decided to do it whilst rolling out the other specialties as well. But I just loved the fact that I'm never bored at respiratory. And I mean that's part of the reason that I chose medicine in the first place. But the days are always very varied and I've always quite liked procedures. So the fact that there'd lots of procedures that keeps you interested and keeps your day very varied was one of the main reasons that I did it.

SPEAKER_00 2:08

And that actually goes very nicely to my next question, which is what is your typical day life? But I gather that you said no day is the same. So could you maybe talk us through what a typical week is like?

SPEAKER_01 2:21

So obviously on calls are very, very different to your day life as a registrar, and also your day life at a district general is very different to a tertiary. But my usual days at the minute are when you're in a tertiary centre with respiratory, as with other specialties, you do certain rotations of each of the different subspecialties within respiratory. So over the last couple of years, I've covered a bit of cystic fibrosis and there's cancer, there's interstitial lung disease, COPD, TB, asthma, lots of kind of different subspecialties. So at the minute I'm doing sleep medicine. So I'd say a standard day would be a sleep medical clinic where I get supported by the consultants in a specific specialty and see some of the more complicated patients that you might not get that kind of coverage in district generals, not always. And then I'd maybe spend the afternoon doing a bronchoscopy list or doing plural procedures or supporting on the wards. It's completely different every day, and that's the best thing I think about the job.

SPEAKER_00 3:21

Okay, so what does sleep medicine actually involve? Because I do think it's what typically comes to mind when someone does think about respiratory as a career. I think you know the other things that you mentioned, cystic fibrosis, lung cancer, distitial lung disease is what we tend to think about when we think about respiratory. So what is sleep medicine and what do you do as part of that rotation?

SPEAKER_01 3:44

Sleep medicine is really interesting actually, because I agree, you don't typically think that it's a respiratory specialty, but I guess there is overlap with neurology because there's a lot of neurology involved in it as well. But I guess the primary thing with respiratory ventilation, because a lot of people in sleep, so you've put your sleep at your obesity hype ventilation syndrome, but also like your motor neuron diseases, any of the kind of conditions that require you to have long-term ventilation overlaps with the sleep. So we cover like a lot of ventilation, which is really interesting, but at the same time, you see all the really weird and wonderful like REM sleep disorders, we see insomnia, we see loads of the really interesting things that I thought was covered by neurology, and I'm sure there will be some neurology cover there, but we see a lot of that in sleep clinic as well.

SPEAKER_00 4:31

And in sleep clinic, and I will get back to you know pure spiritual, but as you can tell, I'm quite interested about this. Is it where you actually see the patients sleeping, or do you watch a recording of what they have done in the sleep unit that you may have?

SPEAKER_01 4:45

So we are incredibly lucky in Leeds where we have a fantastic sleep service, and the sleep service team that is very much not run by the medical team, they do all of that and they actually interpret a lot of it for us as well. So we don't actually see the patient sleeping, although I think it will be looked at by the consultants that are much cleverer than I am. But we tend to get a report from the technicians and the sleep team having done that assessment themselves, and then we can use that report in discussing with patients and making a plan.

SPEAKER_00 5:15

Very interesting. I will, however, move us back to respiratory. And you mentioned a bit about practical procedures, and could you maybe just talk us through that? Because I know a lot of trainees do think about what practical procedures are involved in a job, and that can either make it or break it when they do make those decisions. So, what kind of procedures do you get involved in and what kind of training is required for them?

SPEAKER_01 5:41

So I guess there are kind of mixed feelings about the procedures. Some people really like them and some people don't. And the primary procedure that we do pretty much every day are the plural procedures. So you can become ultrasound trained where you can use ultrasound to look in the chest and see whether or not there is fluid there and assess whether or not you think that fluid is infected and make a call as to whether or not that fluid needs to come out now or can be dealt with in a couple of days once you've stabilised patients and things. So I find it really interesting. It's an imaging thing that I never thought I would be able to do. And actually being able to walk around with an ultrasound probe in an emergency situation is really helpful. If you've not got the time to send someone to a CT scanner or something, you can put a probe on their chest and see really quickly how sick you think they are, and you can do something about it really quickly, which is again something that I really liked about respiratory, is I felt like it was something that I had the power to fix. Whereas things like the heart, I never really understand how to fix the heart for me. I found really helpful. So you become ultrasound trained, which is a really good skill. And part of that means that you can do plural procedures and you can do a diagnostic aspiration where you take out a little bit of fluid just to see what's causing it. You can take off a litre and a half of the fluid, which is called a therapeutic aspiration, and that takes off a lot of fluid and makes the patient feel better, but also gets you samples for diagnosis, or you can do really cool things like put chest strains in, you can put long-term chest strains in, and you can also do which feels a little bit like a surgical procedure, but there's something called a thoroughchoscopy, and that is when it's a completely sterile procedure done in almost a surgical environment that it's done by the respiratory physicians, and that's when you essentially go into the chest with a probe, you can look all around the thoracic cavity, look at the pleura, assess the pleura, look at the lung, and take samples from the pleura as well. So that's a really cool thing that they get to do as well in terms of hearing all things, and you do them all the time. And then bronchoscopies and e-bus, which is an endobronchial ultrasound, is when you go in with a scope and have a look around the airways of the lungs, and you can take samples from that and with an e-bus. You're looking at the lymph nodes in the mediastinum and around the lungs, and then you can take samples from the lymph nodes as well, and that's basically used for staging cancer and ruling out things like TB and lots of other respiratory things, but we also do those every day for patients that are on the wards and patients that are outpatient.

SPEAKER_00 8:10

And are there specific courses that you need to go on to gain competency in these procedures? Or is it very much part of your training program and it's something that you just learn as you go along and do you have time built into your rotor for it?

SPEAKER_01 8:26

100%, yeah. So I would say that you don't need to do any courses because you will be seeing this every day and being taught it every day. So it's very hands-on specialty. If you're in a centre where you've got senior regis, they'll be teaching you, the consultants will be teaching you, it's very practical and it's hands-on. If anyone is thinking about doing respiratory, then what I found helpful as a junior doctor was I did do an ultrasound course, and that just meant that I could then go and get out on the wards and be practicing while I was a junior doctor. And that's something that you can use as your commitment to specialty if you're then going to apply to respiratory. If you say that you've already done an ultrasound course and you've been practicing scanning, and that shows your commitment to the specialty, but things like bronchoscopy and either site wouldn't do.

SPEAKER_00 9:10

And can I ask which course you did? Because I remember I did one as well to show commitment to my specialty, but I did uh the field course, which I thought was quite useful and was actually quite good for several specialties.

SPEAKER_01 9:21

So there are a lot. I think it's easy to kind of go down that rabbit hole. I did specifically the assessment of the unwell patient, which was a famous course. So there's a thing called famous, which is also good for acute medicine, but that shows you how to scan for DVTs, look at the kidneys, look for uh sightings, and you can also briefly look at the heart, but again, I wouldn't say as competent as that. But you look at the heart and you look at the chest. So it's actually a really good thing for acute medicine and respiratory, and I'm sure it's transferable to lots of things, but that just gets you a general ultrasound understanding and experience. If you wanted to specifically do the chest, there are some, and I'm more than happy to share the links with you for that.

SPEAKER_00 10:04

Excellent. So what we'll do then is I'll just put it in the podcast show notes so for anyone listening, they can always refer to those. So thank you so much for that. And you mentioned before, if we just briefly cover the dreaded topic of uncalls, you mentioned that they can be quite different in a tertiary to a district general. Do you mind if we just briefly, and obviously this will vary depending on you know whereabouts in the country you work, but if you briefly just tell us a bit about your experience between working in the two?

SPEAKER_01 10:33

Yeah, of course. I think you know, most people's fear about going into registrar training is the fear of the medreg, isn't it? And I think it's a very genuine fear, but actually, if I'm allowed to say this, I think it's far better than being a junior doctor. Like there are lots of perks of being the medreg, and it is scary, but once you do it, you realise that, you know, people listen to you when you're the medreg and actually you start to realise that you know more than you think you do. And if you don't know, you always have time to give yourself five minutes and have a little look and think about it. And there is always someone more senior that you can ask anyway. But so for respiratory, whether or not that's different elsewhere, but for respiratory, you do a couple of years of district general and then a couple of years of just being a respiratory reg rather than a med reg. So I would just currently just take calls about respiratory patients that are unwell. And a lot of people in our tertiary centers are sort of your fairly basic asthmatics or COPD patients would go to medicine and then respiratory would just take COPD patients, for example, that were on home oxygen or a bit more complicated or home ventilation, and we kind of have a set criteria that we take directly to respiratory, and that's just so that we can manage the people that need us sooner. Obviously, bed issues are a problem with every specialty. So my typical day at the minute is just taking calls on respiratory patients, and I would also go and see the unwell respiratory patients that are on other wards or a lot of plural things as well. A lot of patients in other specialties get plural infections after pneumonias or lots of other causes. So we get calls from other wards about patients and they might need to come over to us for intervention. But as a medreg, obviously you cover all of the medical specialties, but I would say that respiratory is still the primary thing that we deal with as a medreg as well. You know, there's a lot of overlap.

SPEAKER_00 12:18

Definitely. I think the respiratory problems are my fear when I'm medreg on crawl. The unwell asthmatic actually gives me palpitations. I I just can't, honestly, I don't think I'll ever be able to get over that fear.

SPEAKER_01 12:33

Yeah, we would love that. For me, I think again, as I'd said with respiratory, maybe it's just because I seem to understand the lungs, but you know, I feel like with respiratory, there's always something that can fix it, unless there really isn't. And then that's kind of another reason that I like respiratories. There's also an overlap with palliative care. There's such a wide range of ages of patients that you see with respiratory and conditions. You see a lot of the younger asthmatics and now the cystic fibrosis patients and lots of congenital lung issues, but then you see the older patients that are getting things like cancer or COPD, and then you've kind of got that wide range of ages and patients and different interventions, and then you've got the palliative side as well of knowing when not to do something or when to focus on comfort care. So that's something for everybody.

SPEAKER_00 13:19

No, definitely. And to dispute that. So what advice would you give to juniors that are interested in doing respiratory? I know that you've already mentioned, you know, possibly do an ultrasound course, but what other advice would you give to them?

SPEAKER_01 13:34

So ideally, if they can get a respiratory placement, obviously I know it's not always possible that respiratory placement is the best thing to do to kind of get a feel of it to know whether you want to. And if not, I'm sure if you spoke to your supervisor, well, you could get some taste a days or a taste a week or something just so that you can try it. But what I did was because part of your training as a junior won't necessarily mean that you go to a bronchoscopy list or get too involved with plural procedures, but I would make a sort of bigger effort to try and see some of those procedures and get involved. Go and follow the registrar for a day. I know we're more than happy to take juniors with us, and I'm sure your registrar will be more than happy to share the love. So just go and see what they do, and you know, you'll see some of the more exciting things when the registrar goes down to recess and sees a really sick patient that you would be completely overwhelmed with when you first see one, but actually seeing how the registrar can handle that might just be a good thing to see. I certainly found that helpful and definitely getting involved in the ultrasound. They ended up doing a lot of plural procedures as a junior just because my team knew I was interested in and involved. If they know that you want to do it, they will definitely want to help you. And what skills do you think a respiratory doctor needs? Oh, good question. I think that the hardest bit about being a respiratory registrar, and again, I don't know if that is just the same for everyone, is it I call it decision fatigue. So the hardest thing I find is when you're getting asked lots of different questions from lots of different people about lots of different patients. I just find sometimes that you can just get decision fatigue because you're having to deal with a lot of things, but that comes being any kind of medical registrar, whatever your specialty is. And I think I always found the rule that I learned from both being a med reg and a respiratory reg was if I've sat on a problem for more than 10 minutes, if I've sat down and I don't know what to do about it, then call the consultant. And that's just always been my role of if you can't move on from something, then you need to ask someone else, because otherwise you're never going to get through that huge bulk of the decisions that you need to make. And I found that really helpful. That was just my rule. And at the same time that helps the juniors if you're on a night shift and you don't know whether to phone either your registrar or a consultant. If you've sat on it for 10 minutes, then just call someone else because you just won't be able to move forward for you. So I think being able to kind of know how you work and be able to kind of recognise when you're in that mindset is one of my tips. But skills-wise, I think looking at all of my fellow regis, they're all completely different people. So I wouldn't say you have to be a set personality, but if you like the mix of there being lots of different opportunities and you like medicine, so you get to do a bit of both because there'll always be overlap, and that's definitely uh you know good personality trait to have. But for me, skills-wise, you know, if you like practical things but don't want to be a surgeon, then respiratory is a really good kind of middle ground there. But being able to have that wide scope, I think.

SPEAKER_00 16:30

Good. I'm definitely gonna take that as my learning point of today. If you sit on something for 10 minutes, then just let ask ahead. I love that. Thank you. And my final question, if it's okay, Nathan, you can you know abide by patient confidentiality and something comes to mind. Do you mind just sharing with us a clinical case, maybe, or a patient that you think encompasses exactly what respiratory is all about?

SPEAKER_01 16:57

Yeah, definitely. The fascinating thing about medicine, and particularly respiratory, is that the answer isn't always clear-cut and actually you have to involve other specialties, and not everyone's always going to agree because no one's ever black and white. And there was a young lady who had something called anti-symptase syndrome, which is a really rare but horrible rheumatological disorder that quite young people can get. And these patients get interstitial lung disease, but they normally kind of get the more inflammatory rather than fibrotic type of interstitial lung disease. But this lady ended up being very, very poorly and had come into hospital with changes on her scan that very much looked like PCP, which is something that people get when they're immunosuppressed, and you give them CERN antibiotics for that. But there's also a lot of diagnostic uncertainty that happens very commonly where you get these kind of changes on a CT scan, which you're wondering whether or not it is a new infection or whether it's worsening of disease. And we involved the rheumatologists, we involved intensive care, we spoke to the interstitial lung disease specialists at leads. There were lots of different people involved with this lady who we still weren't really sure whether or not this was an immunosuppressed infection or whether it was progression of her disease. So we had to cover all bases, and she ended up getting high-dose antibiotics, she got parsimon exchange and all of the really like fancy things that the rheumatologists deal with that you know needed improvement from higher orders and stuff. So there was lots of treatment that we threw at this lady. Unfortunately, she did pass away, but there was a lot of interesting discussion around it and uncertainty, just doing everything that we possibly could for her. And that's one of the things that we see. So it's not a happy ending, but there was a lot of sensitive discussions with the family and lots going on in the background with lots of different specialties, and it was very interesting. But it just highlights a lot of overlap with other specialties, such as rheumatology, involving intensive care colleagues, and also dealing with the palliative side of things, unfortunately. And did you ever find out what the cause was? I think the fact that she got so poorly so quickly, it is something that you see in catastrophic interstitial lung disease. And so I think the kind of conclusion that we came to was it was probably that she'd been on steroids for a very, very long time because of her lung problems and her rheumatology problems, and that can make you immunosuppressor infection was still possible. But the fact that she got worse and worse and worse and was needing more and more oxygen and more support is something that we do see with catastrophic interstitial lung disease, sadly. It's one of the specialties that is certainly moving forwards with antifibrotic treatment, but you still see really tragic cases like this.

SPEAKER_00 19:42

Very interesting. Thank you, Natalie. So I guess that brings us to the end of my questions. Any closing remarks from yourself for anybody that might be interested in following a career in respiratory medicine?

SPEAKER_01 19:56

I guess the one thing I would say is don't let COVID put you off. I think a lot of people thought, oh no, I'm not going to go into respiratory because COVID, obviously, yeah, you can't get through anything without bringing that up, can you? But I think there's so much more out there that, as you said, like you didn't even know that sleep was a respiratory specialty. But there's so many interesting avenues that you can go with respiratory, but you'll always have your toe in medicine and other parts of medicine, even if you're at a tertiary centre. So if it's something that you're interested, and obviously I'm more than happy for them to contact me as well if you want to give them my email. But it's a really interesting specialty. So if you're interested, just go and have a look and get involved.

SPEAKER_00 20:35

Thank you so much. Thank you for all your wise words. Thank you very much. 10-minute role that I'm sure will stick with all of us. And thank you for being so inspiring. And I hope you have a good rest of your day. For anybody listening, if you want to listen to our other careers podcast, then you can obviously do that on the career conversations channel. We do also do clinical conversations where we pick lots of different clinical problems that you may encounter on the wards and we discuss a diagnosis and management. So thank you everyone for listening. And Natalie, thank you again so much for joining me today. No problem at all. Thank you.