Royal London Hospital

The Royal London Hospital is a large teaching hospital in Whitechapel. It is part of Barts Health NHS Trust. The Royal London provides district general hospital services for the City and Tower Hamlets and specialist tertiary care services for patients from across London and elsewhere. There are 675 beds in the new building which opened in February 2012. It has a helipad!

The latest CQC report rated it as “requires improvement” across all domains, an improvement on the previous “inadequate“.

The Respiratory Job

Consultant speciality interests

• Dr Veronica White – TB
• Dr Heinke Kunst – TB
• Dr David Simcock – EBUS/sleep and vent
• Dr Will Ricketts – Lung Cancer
• Dr Ali – Asthma and allergy
• Dr Danie Watson – infection

Meetings

• Lung cancer MDT attended less than monthly
• Weekly radiology meeting
• Monthly clinical meeting/journal club
• Mortality and morbidity meeting attended less than monthly
• Weekly grand round

Bronchoscopy

• Adequate Bronchoscopy experience including endobronchial biopsy.
• Transbronchial biopsy rarely done.
• EBUS is available in the hospital (RLH). It is mainly done by Consultants but there are some learning opportunities for trainees.
• There have been issues with supervision of Bronchoscopy lists in the past, which caused problems when less senior trainees went to these posts. This is being addressed. It is still not felt to be appropriate for ST3-4s or those will limited Bronch experience.
• Since starting EBUS, the number of Bronchoscopies has reduced, which has affected trainee logbook numbers.

Clinics

• 1 TB clinic every 2 weeks on average
• 1 sleep/vent clinic every 2 weeks on average
• 1 general respiratory clinic a week
• 1 asthma clinic, every 2 weeks on average

In a typical week the SpR will do 1 TB and 1 General Resp clinic. On the odd occasion when there are 3 SpRs around,  the clinic SpR would do 1 difficult asthma, 1 TB and 1 sleep and vent clinic.

Typical week

A typical week consists of 1-2 clinics, 1 bronchoscopy list, and 3 consultant ward rounds. The remaining time is spent on ward work and referrals. Unfortunately there is no dedicated administration time. The job is very busy, often necessitating early starts and late finishes. But there is plenty of pathology, and a very supportive consultant body.

You mainly rotate between inpatient Resp (2 wards shared with cardiology and infection/immunity teams, no dedicated beds and so numbers can fluctuate significantly between 20 and at its worse 40 patients), outliers and referrals SpR (including all new Resp patients) and GIM. The outlier SpR will attend 2 clinics each week, the ward SpR will attended two Bronch lists per week.

Procedures (estimated per year done by each Resp SpR)

• Chest drains: 5 – 10
• NIV initiation: 25+

Pleural USS

• A bedside ultrasound machine can be borrowed from A+E. No dedicated departmental machine at present.
• There is no Level 2 accredited Consultant so sign-off is not a realistic prospect at present. There are Radiology SpRs but they are hard to pin down for sufficient time.
• Dr Barmania is Level 2 but works in acute medicine, not Respiratory.

GIM

• Each specialty has acute take slots which are then allocated within the specialty. This has led to some SpRs doing significant amounts of GIM when there have been gaps here.
• Each on-call consists of
  • Day SpR 9am-10pm
  • Ward SpR 9am -10pm
  • Night SpR 9 pm – 10am
• You tend to do 4-5 of these over 4-6 weeks before having a period back on the wards. Unfortunately there are regular rota gaps which make it challenging. A Consultant is onsite for most of the day take so post-taking occurs in good time. There are a good number of juniors at night although not many clerking during the day.
• Each day there is a take triage meeting where all acute admissions are allocated according to specialty and so naturally respiratory receives a significant proportion.

Teaching

• Simulation facilities
• Observed undergraduate teaching
• Observed postgraduate teaching
• PACES teaching

Management/leadership

• Teaching programme organiser
• Journal club organiser

Specialist training opportunities

• Allergy (at St. Bart’s)
• ILD

The main problem is finding time to attend specialist clinics/meetings. HIV and TB are managed by specialist teams, and a special effort and the use of study leave is needed to get experience.

Research

• No specific opportunities highlighted, although several of the Consultants are actively involved in research

Stage of training best suited to this rotation

• ST5

 Recent trainee comments:

“Since the loss of the 4th SpR there has been less flexibility to attend clinics although attempts have been made to employ long term locum SpRs.”

“There is a rich mix of complex and interesting respiratory work. Highlights include complex pleural infections with support of IR with very few patients having to be referred on for surgery. The renal service also provides interesting referrals, mostly infection related. Drawbacks include limited NIV (only 3 acute inpatient beds with the remainder going to HDU), and limited thoracic US – although with new consultants recently recruited training should improve. Very much a culture of allowing IR to insert all drains but once again this can change if trainees are enthusiastic. There is limited access to specialist clinics given the current timetable structure which can be frustrating.”