Consultant physicians working with patients - Royal College of ...

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2 Specialties Respiratory medicineRespiratory medicineDr Lisa Davies BMBCh FRCP Consultant respiratory physician1 Description of the specialtyWho are the patients?Respiratory medicine is a varied, exciting andchallenging specialty. It is concerned with the diagnosis,treatment and continuing care of children and adults ofallageswithawiderangeofmorethan30respiratoryand related conditions.Main disease patternsThe second edition of Burden of lung disease 1emphasised the immense and growing health andeconomic burden of respiratory illness in the UK. ADepartment of Health (DH) review showed that thetotal spend on respiratory care in 2008–9 was£4,247,325,000. 2 Respiratory diseases kill one in fivepeople – more than ischaemic heart disease. Nearly30,000 people die of chronic obstructive pulmonarydisease (COPD) every year, and lung cancer kills morewomen than breast cancer. Respiratory conditions arethe most commonly reported long-term illness in babiesand children, up to one in five adults consult a GP for arespiratory complaint annually, and respiratory diseaseis the second most common illness responsible foremergency hospital admission, with cases of COPDtaking up more than one million bed days in Englandalone.Disease areas include: airway diseases:– nasal, upper and middle airway problems– asthma and other small airway conditions– COPD sleep-disordered breathing diffuse parenchymal lung disease (DPLD) andsystemic diseases that affect the lung:– inflammatory and scarring lung conditions– sarcoidosis– pulmonary manifestations of systemic diseasesand drugs pleural conditions:– malignancy– pleural effusion– pneumothorax– conditions of the chest wall, thoracic spine anddiaphragm occupational lung disease allergic lung and bronchial disorders infection:– cystic fibrosis– bronchiectasis– tuberculosis (TB)– pneumonia and empyema– infective and non-infective pulmonary disordersin immunocompromised hosts critical care and lung failure (acute and chronic) pulmonary vascular diseases:– pulmonary hypertension– pulmonary haemorrhage– pulmonary embolism lung cancer and mesothelioma genetic and developmental lung disorders paediatric lung diseases end-of-life care for malignant and non-malignantlung conditions public health:– smoking cessation and tobacco and nicotineaddiction policy– epidemiology and prevention.2 Organisation of the service and patternsof referralA typical serviceThe typical service provides many components thatcontribute to respiratory care delivered over whole-carepathways, including care at home, in the communityandinhospital.C○ Royal College of Physicians 2013 225
Consultant physicians working with patientsPrimary care and community modelsof careThe British Thoracic Society (BTS) works closely withthe main primary care professional respiratory group,the Primary Care Respiratory Society (PCRS-UK), tocampaign for and plan delivery of expert integratedrespiratory care in the community through Improvingand Integrating Respiratory Services in the NHS(IMPRESS; www.impressresp.com), a joint initiative ofthe BTS and PCRS-UK. Many GPs provide chronic carefor patients with asthma and COPD, which is oftendelivered by practice nurses. A few GPs with a specialinterest (GPwSIs) in respiratory medicine have beenappointed. Respiratory medicine has been and remainsat the forefront of developing integrated services (seesection 7).Hospital-based careMost respiratory physicians continue to have a majorcommitment to the care of acutely ill medical patientsin the emergency admission department. Respiratorydisease remains the second most common cause ofemergency hospital admissions and, although the roleof the acute physician is expanding in some acutemedical trusts with more of these specialists nowrunning medical admission units (MAUs), specialtyinput at the ‘front door’ and beyond must not becompromised. The national COPD audit of 2008 3found that only 53% of patients admitted with COPDexacerbations were under the care of a specialistrespiratory team. The care of these patients and otherrespiratory inpatients with life-threatening conditions,such as acute asthma, severe pneumonia andpneumothorax, and the need to provide advice forinpatients under the care of other medical andsurgical disciplines have a significant impact onworkload.Most outpatient referrals are from GPs, specialistcolleagues in the hospital and the emergencydepartment. Suspected cases of lung cancer and TBshould be seen within 2 weeks, but facilities are alsoneeded to allow all other urgent referrals to be seenpromptly.Regional hospital carePatients with certain conditions, such as cystic fibrosis,are usually managed in regional centres and networks.Surgical and radiotherapy services and more complexbronchopleural medical interventions are usually basedin regional or subregional centres. Supra-regionalcentres exist for the assessment and management ofoccupational lung disease, pulmonary hypertension,complex assisted-ventilation needs and lungtransplantation.3 Working with patients: patient-centredcareWhat you do with patientsInvolving patients in decisions abouttheir treatmentIn 2009, the BTS established the Public LiaisonCommittee (PLC) to ensure that the society benefitsfrom access to informed and involved publicinvolvement in the planning and execution of all of itswork. Respiratory physicians are totally committedto these concepts and are aware of the crucialimportance of cultural and ethnic issues; discussionsand educational sessions on ethical matters takeplace regularly at educational meetings of theBTS.The care of patients with asthma and COPD providesexamples in which self-management plans have longbeen developed by respiratory physicians workingjointly with Asthma UK and the British LungFoundation. A number of respiratory physicians arealso involved in the Health Foundation’s Co-creatingHealth initiative.Every respiratory clinic will have locally and nationallyproduced information leaflets available in differentlanguages. These are often provided by the BritishLung Foundation, Asthma UK and TB Alert, amongothers.Patients are offered copies of letters to GPs andaccess to their medical records if requested.Respiratory physicians have developed trainingprogrammes and materials for breaking bad news tothose with cancer and other life-limiting lungconditions, which include the IMPRESS DVD Livingand dying with COPD.Patients with long-term conditions, patientsupport groups and the role of the expertpatientThe specialty recognises the vital importance of apatient-centred service. Asthma, COPD, cystic fibrosis226 C○ Royal College of Physicians 2013
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