Royal Free Hospital

The Royal Free Hospital was the first hospital to provide free care and the only London hospital to stay open during the 19th-century cholera epidemics. Today the Royal Free Foundation Trust runs the Royal Free Hospital, Barnet and Chase Farm. Specialist services include cancer, neurosciences, HIV and liver, kidney and bone marrow transplantation, as well as haemophilia and amyloidosis. The Royal Free Hospital has approximately 800 beds and sees 85,000 patients in A&E per year. The latest CQC rating was “requires improvement” overall.

The Respiratory Job

Consultant speciality interests

• Dr Anant Patel: lung cancer, EBUS, pleural (joint clinical lead)
• Dr Swapna Mandal: sleep medicine, ventilation (joint clinical lead)
• Dr James Goldring: medical education/training, EBUS, pleural
• Dr Marc Lipman: HIV, TB, infection
• Dr John Hurst: alpha1-antitrypsin deficiency, COPD
• Dr James Murray: lung cancer, EBUS
• Dr Hugh Ip: lung cancer, EBUS, pleural
• Dr James Brown: TB, infection, asthma
• Dr Nikesh Devani: sleep medicine, ventilation
• Dr Simon Brill (Barnet): asthma
• Dr Amina Jaffer (Barnet): bronchiectasis

Meetings

• During lung cancer rotation – attendance at diagnostic (Monday pm) and treatment (Tuesday pm) lung cancer MDTs
• When not on lung cancer rotation – weekly attendance at Radiology meeting (Wednesday 11am-noon)
• Weekly departmental teaching Thursday 1pm – joint with Barnet with presenters alternating from each site
• Rare attendance at M&M
• Hospital Grand Rounds (most Wednesdays 8am) + morning report (every Tuesday and Thursday 8-8.45am)

Bronchoscopy

• During lung cancer rotation, twice weekly bronchoscopy/EBUS lists with trainees encouraged to participate in most procedures (Tues am and Fri am)
• Usually 2-3 EBUS and 1 bronch on each list
• Transbronchial biopsies rare
• Suitable for ST3/4
• Variable supervision/learning environment dependant on which Consultant is supervising the list. Opportunity for very good teaching, even for those who are experienced, with focus on safe sedation, best technique for BAL etc.
• Bronchoscopy simulator available in the hospital (but charge to access)

Clinics

• Lung cancer rotation
  • Weds am lung cancer clinic (Patel/Murray)
  • Weds pm pleural list (Patel/Murray/Goldring/Ip)
  • Thurs pm general respiratory clinic (Goldring)
• Infection rotation
  • Tues pm TB clinic (Lipman/Brown)
  • Weds pm bronchiectasis clinic (Jaffer)
• Asthma rotation
  • Tues pm asthma clinic (Brill/Brown)
• Sleep/vent rotation
  • Tues pm sleep/vent clinic (Mandal/Devani)
  • Fri pm sleep/vent clinic (Mandal/Devani)

Typical week

The Royal Free respiratory job now has a specialty-themed rotation structure, where 4 trainees (3 from North Central & East and 1 from NW London) rotate through each of 4 three-month blocks over the course of a one year placement. These are lung cancer, infection/TB, asthma and sleep/vent. The trainee on each block will be primarily expected to cover the clinics and any relevant procedure lists during that block, as listed above.

However, it is still expected that trainees will cross-cover for each other during study/annual leave. There is also an IMT3 who is expected to attend a range of the above clinics, either as extra support or to cover leave. The ward operates on a consultant of the week system, with a separate consultant allocated to discuss referrals. The ward is usually covered by the FY1s/FY2/IMT2 +/- the IMT3 or whichever trainee is on the asthma rotation, although this is flexible.

During lung cancer and sleep/vent blocks, there is no GIM commitment, with trainees instead covering respiratory 5-8.30pm on weekdays and 8am-5.30pm at weekends on a 1 in 6 rota.

During asthma and infection/TB blocks, trainees are on the GIM rota, which is 1 week of day take, 1 week of evening ward (tower medical) cover, and 1 week of nights, each split into Mon-Thurs and Fri-Sun, on an 18-week cycle. Overall this does not add up to that many shifts compared to some other hospitals on the rotation.

Lung cancer is probably the busiest single rotation with programmed activities – including 2 x MDT, 2 x EBUS/bronch, pleural list and two clinics per week. Trainees on this rotation usually spend less time on the ward and are focussed on gaining these skills.

Sleep/vent primarily look after patients being managed for T2RF on the ward, which is often around 5 patients. The trainee on this rotation will usually do a daily ward round (consultant led twice a week), attend sleep/vent clinic and sleep/vent MDT as well as lead on any sleep/vent referrals.

The asthma rotation is probably the lightest in terms of clinics (1 clinic / week at the moment, although historically also did ILD before the service stopped), and this SpR is also theoretically supposed to help on the ward and lead on referrals, although in reality this role is often split.

Infection/TB is a great learning opportunity to be part of the TB/complex infection and bronchiectasis clinics as well as attend the very interesting weekly respiratory infection radiology meeting with the ID team.

The referral system now via email for routine referrals (there is still a bleep for urgent issues and NIV) and it can be very variable how many referrals are required. SpRs see all referrals and some of these patients can be complex (due to the other speciality interests within the hospital eg ID, Renal, Transplant). In practice often it is often a full time job for one trainee to be seeing and discussing all referrals.

Procedures (estimated per year done by each Resp SpR)

• Chest drains: 20-30
• Abrams biopsies: 0-1
• NIV initiation: 20-25
• Ascitic drain/top: 0 routinely, can be arranged via hepatology
• Central line: 0
• Lumbar puncture: 0-5 routinely, can be arranged via neurology

Pleural USS

• Weekly pleural clinic and lots of ad hoc teaching opportunities. Also opportunity to learn IPC insertion and pleural/peripheral lymph node biopsies which are performed less frequently at other hospitals.
• There is a dedicated Respiratory Department machine

NIV

Between 8am-8.30pm, respiratory SpR is responsible for liaising with ED for initiation of NIV and NIV is set up on the respiratory ward (8E) or ITU. The Royal Free uses IVAPS ventilation, rather than fixed pressures. Idiot-proof protocols on how to do this are attached to the NIV machines, but just make sure you have a look at them when you start if you are not familiar with IVAPS so you are prepared. Dr Mandal also arranges NIV online + practical training for most trainees soon after they start.

GIM

• Acute medicine is well supported and takes are manageable, and there are several specialties who have separate on calls.

Teaching

• Simulation facilities are available including a Bronchoscopy simulator (which can be accessed by you)
• Observed undergraduate teaching (lots of UCL students around and opportunities to teach), contact Dr Murray if interested in greater involvement in teaching
• Observed postgraduate teaching (eg IMT)

Management/leadership

• Rota and teaching organisation
• Junior doctor forum
• Management course available

Specialist training opportunities

• Pulmonary Hypertension service within the hospital – specialist experience can be arranged here, though informal feedback suggests the Hammersmith offers a better experience. Study/annual leave would be required to attend clinics/lists
• Specialist alpha-1 clinic (but not formal part of rotation)
• Weekly TB clinic during infection rotation.

Research

• Marc Lipman and John Hurst are active in research and are often on the lookout for trainees to join them in standalone projects or fellowships. The Free is also a site for a number of pleural trials – speak to Dr James Goldring for more information.

Stage of training best suited to this rotation

• ST5-6 (less supervision, some complex patients)

 Recent trainee comments:

“Looking after some of the more complex patients e.g. haematology/renal/transplant patients with difficult respiratory infections is great experience.”

“The Free job is good, with a supportive Consultant body and good training. There is variable supervision, and with some complex patients it’s better suited to later on in the training programme. Being in Hampstead is not bad either!”

“Can be an intense place to work but great opportunity to deliver high quality respiratory care.”