Thoracic medicine presents a unique opportunity to study one of the
vital organs of the body. The specialty is academically challenging
and combines the disciplines of physiology, anatomy, radiology and
pathology. It has an extremely long history and covers a vast (and
expanding) range of illnesses and treatments. Since it is primarily
diagnostic in character, thoracic medicine requires keen clinical
insight and discernment. It also presents opportunities for a wide
range of interventional procedures and offers a spectrum of
lifestyles - from shift work and acute critical care medicine to
non-clinical laboratory based lung physiology.
As in all areas of medicine, you need to possess clinical acumen and
an ability to communicate with patients. Thoracic medicine in
particular requires a good understanding of the underlying
pathophysiology of respiratory disease, so you should have an
inquisitive mind and be interested in the basic mechanisms of
illness and disease. Aptitude for developing procedural skills for
invasive interventions is also important.
Thoracic medicine offers opportunities to combine both
hospital-based and private practice. For a hospital specialist,
day-to-day work would usually encompass care of inpatients with
respiratory illnesses ranging from common diseases through to those
requiring specialist tertiary care (including acute respiratory
emergencies and transplant medicine). Outpatient clinics would
involve new cases and long-term follow-up of conditions such as
asthma, chronic obstructive airways disease, interstitial lung
disease, bronchiectasis, sleep disorders, transplant and
tuberculosis. There is also procedural work (such as bronchoscopy,
pleural aspiration, biopsy and drainage), laboratory based work
(including physiology laboratory and sleep reporting) and
consultation to other services. There is increasing demand for
management of non-invasive ventilatory support in the HDU or ward
setting. Most specialists devote time to CME activities, teaching,
research, project work and administration.
Thoracic medicine does have its share of acute emergencies, such
as massive haemoptysis, airway obstruction and respiratory failure,
but the amount of acute emergency work referred to thoracic
physicians depends on the individual hospital’s administration
arrangements. Acute emergency cases may be handled in some centres
by specialists in emergency or intensive care medicine.
A major challenge for thoracic medicine is that many diseases e.g.
COPD are extremely common and are often handled by other specialists
in general medicine. Hospitals may find it difficult to justify
employing a full time thoracic specialist when generalists are able
to absorb simple respiratory cases, leaving only a few isolated
illnesses that require a pure subspecialty interest.
However, the advances that are being made in the discipline should
continue to ensure need for the specialist services of the thoracic
physician. Understandings of disease mechanisms are constantly
improving and technical advances in genetics, immunology and
radiology continue to change the face of diagnostic and treatment
options in many clinical areas such as cystic fibrosis, lung cancer
and sleep medicine. Increasing experience in lung transplantation
and management of its complications will widen treatment options for
previously incurable respiratory diseases. At present
respiratory-related diseases rate in the top three of all hospital
admission statistics in developed countries and lung cancer remains
in the top three for cancer-related mortality. There is a clear
challenge posed to the specialty to alter these statistics.
There are great opportunities within the specialty, especially given
the technical and diagnostic advances that are currently being made.
The area of sleep medicine will continue to develop.
Employment is usually hospital-based, so flexibility for time out to
travel will depend on the particular employer and will vary
according to workforce needs. There is a large ambulatory component
to a respiratory service, which will suit those requiring seasonal
work.
In general thoracic medicine affords a well-controlled lifestyle. A
working week might comprise roughly 50 hours, with call work causing
infrequent disruptions to family life. The call ratio may be higher
if transplant or acute non-invasive ventilation services are offered
by the hospital.
A minor disadvantage, and one that is not unique to thoracic
medicine, is that treatment options sometimes lag behind diagnostic
advances. It can be frustrating to be faced with a difficult
clinical problem for funding for high cost treatments does not exist
or where treatment does not exist at all. On the other hand,
however, this also provides scope and impetus for further research.
Advanced training in thoracic and sleep medicine is popular
and provides opportunities for you to familiarize yourself with all
aspects the two specialties. The programme offers opportunities for
continued learning that include structured teaching, journal clubs,
meetings and self-directed study. Research and project work are
strongly encouraged and well-supported.
