Changing directions?

Changing directions?

  • Issue 62

Crina L Burlacu | Dublin, Ireland

The Department of Anaesthesia, Intensive Care and Pain Medicine at St. Vincent’s University Hospital (SVUH) in Dublin is staffed by 29 Consultant Anaesthetists and 30 Non-Consultant Hospital Doctors (NCHD). The NCHDs are bringing an enormous contribution to the delivery of patient care while benefiting of high-quality training in all areas of anaesthesia, perioperative medicine, intensive care, and acute and chronic pain medicine. As of 2007, an inter-departmental collaboration was set out between our Department and the SVUH Department of Emergency Medicine where emergency medicine (EM) trainees are deployed for a 6-month training module in the specialty of anaesthesia. In more recent times, the Royal College of Emergency Medicine (United Kingdom and Ireland) has made such modular anaesthesia training mandatory for all EM trainees. As such, several EM trainees are regularly joining our Department in order to acquire competencies in patient monitoring, airway management, vascular access, sedation, anaesthesia for emergency cases, etc.

After completion of their anaesthesia module, most EM doctors return to their mother specialty for further training and EM career progression. In the last few years, some have taken up EM consultancy posts (including two in our hospital). Interestingly, a few have decided to change their specialty and become anaesthetists. I was interested in finding out how these doctors felt about our specialty. Therefore, I asked two of these doctors to reflect on their anaesthesia training and share with us their thoughts and ‘on the job’ insight in anaesthetists’ life.

Changing specialities – as seen by a ‘converted’

Dr. Catalin Iulian Efrimescu | MBChB | Specialist Anaesthesia Trainee

Choosing a medical speciality for the rest of one doctors’s professional life could be a highly daunting task. For most of us, this process is fairly straightforward. It is every so often based on an early found unambiguous special interest but more often on previous enjoyable experiences during the undergraduate and internship years. Yet, the pressure of making this choice at an early professional stage without experiencing the pros and cons of a certain speciality could throw one on the wrong path. As a consequence, a minority of doctors decide to shift specialities after a certain period of training in a particular domain.

In general, medical students and interns have limited exposure to the speciality of anaesthesia and intensive care. It requires a certain level of pre-existing medical knowledge and skills in order to understand and enjoy it. For some doctors this may be very intimidating and prevent them from choosing it as a career during their early postgraduate years.

In Ireland, anaesthesia is one of the most competitive training schemes. It offers a highly esteemed comprehensive well-structured training programme. Of the roughly forty doctors recruited for the Specialist Anaesthesia Training (SAT) scheme every year, a significant proportion had undergone basic training in other specialities (e.g. medicine, surgery, emergency medicine).

Enrolling doctors with other speciality background on to the anaesthesia scheme has its advantages. Firstly, it promotes mutual respect and good inter-speciality collaboration. Secondly, such doctors bring a new set of knowledge and skills to the speciality. Thirdly, their previous clinical experience makes them a supportive element for the more junior colleagues. Last but not least, they could be trained in a steeper fashion.

I have asked two of my anaesthesia colleagues about their reasons for choosing anaesthesia over other speciality. Dr. Charles Goh, a former surgical trainee, explained that anaesthesia is ‘’a general speciality that requires a broader medical knowledge’’ which he has chosen because of ‘a better defined training direction’’ and ‘’for the lifestyle and better working patterns’’. Dr. Ronan Motyer, a former surgical and emergency medicine trainee, stated that ‘’this speciality offers an attractive overlap between practical skills and theoretical knowledge’’ with ‘’excellent training, under the close supervision of a consultant and more senior colleagues’’.

Finding my own career path

I am proud to have just joined the College of Anaesthetists of Ireland SAT scheme as a result of a very competitive selection process earlier this year. I have already spent three years on the Emergency Medicine Basic Specialist Training (EM BST) scheme. I am, officially, a ‘converted’.

Anaesthesia had not been my first career choice. As a medical student, I enjoyed the very short optional module in my 5th medical year. Anaesthesia appeared to me as a logical speciality connecting medicine, pharmacology and physiology. Yet, at that stage I was dreaming of cutting patients’ chest open and saving lives as seen on TV (i.e. the ER series). During my initial EM years, I came to notice that the EM trainee’s life is not always as enthralling as seen on TV. At times I felt the frustration of being just another wheel of the huge EM referral machine. Amid a busy clinical schedule, there was very little time for meaningful training and I started to feel that I was not achieving my full potential.

I developed a genuine interest in anaesthesia and intensive care while looking after very sick patients in the resuscitation room together with my anaesthetist colleagues at times. Suddenly, the role of the anaesthetist became much clearer to me. And I was longing to also follow the sick patients along their hospital journey beyond the doors of the Emergency Department (ED) into the Operating Theatre (OT) and Intensive Care Unit (ICU).

The decisive moment came during a 6-month anaesthesia and intensive care training module which is mandatory for all EM trainees. I found myself in a well supervised training environment which exposed me gradually to a speciality that requires both broad knowledge and practical skills. The close consultant-trainee professional relationship offered me confidence and discipline. I realized that I feel naturally comfortable in the OT and ICU despite being confronted with a multitude of critical clinical scenarios. The prior exposure to a variety of medical, surgical and trauma patients in the ED helped me quickly adapt to this new speciality. Now at the receiving end of the EM referral circuit, I have become more sympathetic to the challenges encountered by my EM colleagues, and respond to their calls in a timely and meaningful fashion.

After thoughts

I do not regret the time that I have spent on the EM training programme although I wish I came to this decision a few years earlier. Starting afresh in a junior position in a new specialty is somewhat difficult. I will need to acquire new knowledge and solid practical skills, and build up my confidence. I may need to abandon bad habits. I will have to sit and pass more exams. I may need to report into younger colleagues albeit more senior on the anaesthetic career scale. I may need to take further decisions in regards to sub-speciality training. Will that be pure anaesthesia ? Will I follow the intensive care route? I feel I am up for the new challenges, and I am confident that this is the right speciality for me. Time will tell!

Reflections of an Emergency Medicine Trainee on Anaesthesia

Dr Elizabeth Little | MBChB | Emergency Department Registrar

As of July 2014, the Emergency Medicine training programme in Ireland is 7 years in duration. A 6-month rotation in Anaesthesia and Intensive Care Medicine is included in the first three years of the programme. The curriculum, as described by the Royal College of Emergency Medicine (UK and Ireland) expects that the trainee demonstrates competency in pain assessment and treatment, rapid sequence induction, ventilation techniques and airway management; including failed intubation. The critical care proficiencies of resuscitation and assessment, monitoring and treatment of shock are also emphasized.

With almost 3 years of Emergency Medicine training under my belt, I approach most situations in a calm composed fashion. However, I have felt that I am lacking expertise in something critical ‐ managing the airway. Yes, I have been to airway courses, and have dealt with difficult and challenging airways in paediatrics, neonates and adult emergencies, but in reality I have always had expert back up! So, embarking on 6 months of anaesthesia training made me rather nervous. These are the people I call when I have run out of options, so how on earth am I going to become one of them? Furthermore, will I want to jump aboard this speciality in the long term?

Throughout my undergraduate and postgraduate training, anaesthetists have been largely an enigma. My impression was that they were aloof, quiet creatures whose natural habitat was the theatre and ICU putting patients to sleep, “fiddling with a few ventilator buttons” and giving inotropes!

Four months into my rotation has not only changed my perception, but also my medical practice. While I still feel that fundamentally I am an Emergency Physician, however the experience has taught me several things I will certainly utilize in my future career:

  • The 7 Ps: Prior Planning, Preparation and Practice Prevents Poor Performance. The fundamental importance of checking your equipment, preparation of drugs, preoperative assessment, adequate personnel and appropriate post‐operative care has been embedded into my practice. This incorporates having alternative patient management plans even in the most “straightforward” of cases. In the remote setting of the Cath Lab or Interventional Radiology, this is particularly essential.
  • Management and leadership skills. Anaesthetists are experts at managing their diverse daily duties, from assessing patients to running theatre lists. But what I most surprised to note is that they are adept communicators, both with their patients, medical and surgical colleagues, nursing staff and porters. My rotation has given me insight into their vital role, ensuring the smooth running of theatres, ICU, PACU and the day wards, in collaboration with hospital managers.
  • Teamwork: we are all human. Anaesthesia requires considerable dexterity and precision, but there will days when any doctor can be in “off form” – on such cases, your colleagues support is invaluable! Personally, the last four months have re‐ignited my passion for medicine. Revising and applying undergraduate pharmacology, physiology, anatomy and physics, certainly make me feel like I am using my academic capabilities, made all the more satisfying as this occurs in conjunction with the crucial practical nature of an anaesthetist’s work. Every day I have managed an unexpected event of one kind or another, and with this experience and all the tubes, gases and drugs no longer activate my sympathetic nervous system!