Career Story: ICM and Emergency Medicine in Scotland

I think it’s important to emphasise early on that my experience will be different to your experience — a lot of changes happen in training, curricula and exams over the course of two decades. Challenges I’ve faced may be very different to challenges you will face; my Job Plan will likely be different to your Job Plan. Don’t let my article sway you one way or another. I can only tell you how things have been for me, not how things will be for you. Sermon over, here are some specifics. 

What was the biggest challenge in securing an EM/ ICM dual consultant post? 

Aside from jumping through the formal examination hoops, CV-building and trying to tick the “good guy” box so that people would actually want to work with me, the biggest challenge came down to two things: 

1. Few people in Scotland had done it before, and
2. Out-of-hours working. 

The second issue was the most challenging. In the far more established anaesthesia/ICM training pathway, many consultants end up doing daytime anaesthesia sessions and doing all their out-of-hours commitment in ICM. This can work well given that a large bulk of anaesthesia workload centres around managing elective cases done during daylight hours so there is more need for daytime cover and comparatively less need for out-of-hours consultant cover. Anaesthesia and critical care are usually part of the same directorate and that can also make job negotiations easier: you are still providing out-of-hours cover for the same overall directorate/department. 

In EM, however, there is a definite need for evening and weekend consultant cover. The result is that you end up approaching two different departments belonging to different directorates and both may want you to do full out-of-hours work for them. I think that for the vast majority of people, that is unreasonable to expect and not sustainable — and therein lies the difficulty and the start of negotiations. 

Was there a clear path for me to follow or was my dual consultant post an ‘in-house’ negotiation? 

It was very much the latter. There had only ever been one previous consultant in my region who worked in a combined EM and ICM post (doing full out-of-hours work in ICM and in-hours work in EM). He later changed to sole ICM. 

I needed to be proactive. Well before my last 12 months as a trainee, I had worked out what my first to fifth preferences for consultant posts and Job Plans would look like and had communicated my first and second choices to the relevant Clinical Leads (being clear that this was a Wish List, not an expectation!). I had also visited the EM and ICM directorates of the other hospitals lower down my list to see what potentials there were for combined posts either contained within one NHS Board or across Boards. Although departments were open to the idea, there had never been dual ICM/EM Consultants in the other hospitals and the logistics would have been more difficult. 

When I became eligible to apply, there had already been two consultants appointed to the largest of the critical care units in the region over the preceding 12 months. Thankfully, the ICU in St John’s Hospital in Livingston had a potential post available and they were also the regional Maxillofacial, ENT, Plastic Surgery and Major Burns Centres. I thought that setup may also help provide additional opportunities for advanced airway skill maintenance and practice in a Centre of Excellence. Out-ofhours, critical care was covered by a mix of anaesthetists and intensivists who also covered Obstetrics, so there was no requirement for me to do out-ofhours work for ICM. 

Most importantly, I had done previous anaesthesia and ICM attachments in the same hospital and absolutely loved the mix of consultant and other senior staff personalities in the departments: so many were fun, supportive, exceptionally talented, actively encouraged discussions around potentially challenging decisions and opinions, and absolutely hilarious. I was keen to be a part of the department, particularly with the strong interworking relationships between the anaesthetists and the intensivists. 

I also wanted to be part of the excellent Emergency Medicine team in the Royal Infirmary of Edinburgh, the busiest ED in Scotland and soon-to-be Major Trauma Centre; it my first choice for EM posts. Consultant posts were advertised for there and, following successful interview, they were keen that I stayed, offering to fund not only my EM post but also the first year of an ICM consultant post in Livingston. If everything went well in that trial and all sides were happy, critical care in St John’s would take over the ICM funding thereafter. Thankfully, we were and they did. 

What does my Job Plan look like? 

In terms of EM and ICM split, this has changed very little over the past nine years as a consultant. I work full-time (currently 10 PAs). 70% of my time is contracted to EM with 30% in ICM. I do all my out-of-hours work for EM. This amounts to a weekend frequency of 1 in 6 and other weekday evenings (17:00–23:00) and nightshifts (covering until 02:00 then on-call until 07:30). My total out-of-hours PAs is 3.25. It is worth noting that the consultant contract for Scotland states that no more than 3 PAs per week should be out of hours other than in exceptional circumstances (1) — that is partly why I believe that doing full out-of-hours for two different specialties is unlikely to be sustainable or desirable for most people. 

I work a block of one week in ICM every 8 weeks. This allows for better continuity of care for patients and also makes rota planning much easier for both departments as I can block out my ICM weeks well in advance. Up until this year, I also did an Extra PA (EPA; an additional 4 hours per week) in daytime EM. I requested it after my first year given that working in two specialties meant I ostensibly had two part-time jobs with a significant proportion of out-ofhours work. I therefore thought it might be a good idea to optionally increase my daytime EM sessions. I’m not sure if this was needed clinically. It also translates into very little takehome pay due to tax thresholds so, both in terms of work/life balance and finance, I’ve dropped the extra PA for this year and I’ll see how it goes. 

Separately, I’m a Simulation Lead for Emergency Medicine and now receive Job-Planned time for that. I’m an EM Clinical and Educational Supervisor and the Morbidity & Mortality Lead for critical care in St John’s Hospital. 

How do I feel about it now and would I change anything? 

I’m very happy with my combined EM and ICM role. Although they can both be high-intensity, highpressure environments, they complement each other. I get to help manage some of the sickest (and for me, the most interesting) patients in the hospital right from the time they arrive and are brought in to Resus and then later in ICU and thereafter. I get to help coordinate large teams in the ED and then smaller teams in the ICU. I get to work closely with some of the most exceptionally talented nurses and allied specialists in the hospital across both specialties, each bringing their own unique knowledge and skills sets, and together we provide truly team-based care. 

Every specialty has its ‘heart-sink’ issues. Switching from one to the other and back itself often helps provide some respite: When I get disheartened by managing a massively overcrowded ED at >120 patients and at >400% capacity due to a total lack of inpatient beds, I often get to switch and manage less than 10 patients to a far more detailed degree. When I get disheartened by the slow decline of longer stay ICU patients or the drip-drip emotional impact of having repeated conversations with families whose relatives continue to deteriorate despite escalating therapies and all interventions, I sometimes get to switch to the ED, relocating joints, managing fractures, cardioverting arrhythmias, coordinating medical teams and helping to relieve distress in other ways. 

It’s great to see things from different perspectives and gain insights into the inner working of different specialties and departments. It’s interesting to go from calling inpatient specialties predominantly to refer patients in EM and then to be the one receiving referral calls from the ED or inpatient specialties in ICM. (That actually serves as a constant reminder to try and remain grounded and friendly when receiving referral calls; it will surprise no-one that some people sound very polite and lovely when referring a patient to another specialty but go right to the opposite side of the incivility spectrum when receiving a referral themselves). 

Are there any downsides? 

There are downsides: keeping up-to-date in two high-intensity, acute specialties can be tricky. Working in two departments in different hospitals means that I see staff in both less frequently. I had to accept early on that I needed to give up seeing Paediatric EM patients: I work in an adult ED and an adult ICU; continuing to see paediatric presentations would have meant working across three departments and essentially having three part-time jobs. I thought that would have been ill-advised, giving me too little time in each area. Similarly, being an Emergency Medicine and ICM during a respiratory pandemic was not the most fun experience ever... 

Many of my colleagues in anaesthesia had their lists cancelled or changed to local anaesthesia lists and had issues for a time of having too many staff with too little active operating theatres. I instead flipped back and forth between the carnage of an overcapacity, under-resourced and expanding ICU to the carnage of an overcapacity, under-resourced and overcrowded ED, with deluges of policy, procedure, kit changes and miscellaneous updates flooding in everywhere at all times of day and night from both specialties. It would be very nice not to repeat that. 

Overall, though, despite the pressures that result from our under-resourced health system, I’m very happy in my current roles and grateful for the opportunities and experiences they provide. 

My take home message is this: it’s been worth it; it remains worth it.