Exploring Subspecialties in Respiratory Medicine: Global Career Pathways for Physicians

The Scope of Respiratory Medicine

Respiratory Medicine is already a subspeciality of Internal or General Medicine. In the UK, as in most jurisdictions, respiratory physicians start postgraduate specialist training in internal medicine completing the basic and intermediate training levels before electing to "sub specialise" in respiratory medicine, pursuing advanced or fellowship training in this specialised area of medical practice.

Within most jurisdictions respiratory medicine is a recognised scope of medical practice, secondary to the primary scope of  internal medicine. However some jurisdictions such as New Zealand do not have a registration pathway for respiratory medicine physicians who must therefore register under the scope of internal medicine.

This field of respiratory medicine is a large one as respiratory disease is common worldwide and remains a significant cause of morbidly and mortality. From the routine management of asthma to the treatment of severe conditions including pulmonary malignancy and pneumonia, the respiratory physician has a busy case load ranging from the chronic and mundane to the acute and esoteric.

The speciality is not insular and interacts with a broad array of other medical specialities which include intensive care medicine, general internal medicine, gastroenterology, occupational medicine, ENT surgery, transplant surgery, sleep medicine and public health medicine. It increasingly uses interventional procedures, particularly minimally invasive ones.

The increasing complexity of the speciality prompted the British Thoracic Society (BTS) to suggest that some areas of respiratory medicine required advanced or “super-specialist” training to focus on the management of some problematic pathologies or highly technical interventional procedures.

Core Subspecialties in Respiratory Medicine

The BTS has identified a wide range of subspecialty fields within Respiratory Medicine which require distinct technical competencies and specialised training to optimise patient management. These include:

Asthma:  Whilst primary care services can manage most cases of chronic asthma, severe and refractory asthma management requires specialist oversight and treatment with biologic therapies in tertiary hospital settings.

Bronchiectasis: Primary care services can manage most cases of chronic bronchiectasis but specialised management is essential for chronic airway infection and airway clearance interventions.

Chronic Cough: Specialist respiratory physicians are often referred patients with persistent symptoms which have failed to respond to standard treatments. Diagnostic integration and treatment plans with ENT Surgeons and gastroenterologists are common.

Chronic Obstructive Pulmonary Disease (COPD): Advanced cases require specialist management with medication, oxygen, ventilation and sometimes surgical intervention.

Cystic Fibrosis (CF): Transition to adult services often requires specialist treatment to maintain airways, treat infections and prevent complications.

Interstitial Lung Disease (ILD): Interstitial Lung Disease (ILD) is often diagnosed with significant lung limitation and tertiary care involves supportive care to reduce morbidity, pharmacologic treatments, and supportive non-pharmacologic interventions like pulmonary rehabilitation, supplemental oxygen, and palliative care.

Interventional Pulmonology: Minimally invasive bronchoscopic and pleural procedures for complex thoracic conditions, such as central airway obstruction, benign and malignant lung diseases, and pleural effusions. Techniques include advanced bronchoscopy (EBUS and robotic bronchoscopy), endobronchial thermal therapies (laser, cryotherapy, argon plasma), airway stenting, and medical thoracoscopy.

Long Term Ventilation: The treatment planning and management of specialised care for patients who are not being weaned from ventilation in an intensive care setting and have chronic respiratory failure.

Occupational Lung Disease: The assessment and management of occupational related respiratory disorders focused on managing established, symptomatic disease to reduce complications and consequences

Pleural Disease: Tertiary management of pleural disease is required when standard approaches fail for the management of persistent and malignant pleural effusions and air leaks.

Pulmonary Vascular Disease: Tertiary management of pulmonary vascular disease (PVD) involves pharmacological and procedural intervention ranging from balloon pulmonary angioplasty or atrial septostomy for specific types of PVD to lung transplantation.

Pulmonary Oncology:  Respiratory physicians work with a dedicated tertiary care team of  thoracic surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, and palliative care physicians providing targeted treatment, radiotherapy and surgery.

Sleep Medicine: Respiratory physicians play a crucial role in sleep medicine by diagnosing and treating breathing disorders which occur during sleep, typically obstructive sleep apnea (OSA) and hypoventilation syndromes.

Tobacco Dependency: Respiratory physicians play a crucial role in treating tobacco dependence, which is a major risk factor for respiratory conditions with smoking cessation programmes and preventive health strategies.

Tuberculosis (TB): Respiratory physicians are central to tuberculosis (TB) treatment, with global and public health roles in its prevention, diagnosis, and control.

Additional training in these fields can be undertaken in tertiary medical facilities as fellowships with an average of 6-12 months duration.

Global Demand for Respiratory Subspecialists

Healthcare organisations around the world have strong demand for respiratory physicians in both secondary and tertiary level hospital facilities. The job descriptions should detail the specific skills and experience required including the ability to perform complex interventional procedures. In some secondary level hospitals, the practice of respiratory medicine is combined with general medicine. In tertiary hospitals, an exclusive scope of practice in respiratory medicine is usual, often combined with expertise in one or more of the above fields.

The table below lists the common fields of expertise within respiratory medicine and the typical opportunities available across the regions of the world. This information is useful for physicians planning an international career or time spent overseas as part of a sabbatical.