Finding a consultant post: Why district general ICM was the right choice for me

The final years of training can be somewhat of an emotional roller-coaster – you’re excited to finally see the ‘reward’ for all those years of hard work, but anxious about taking on a new post and responsibilities. Perhaps one of the more difficult considerations is where you want to work as a consultant, and how this will influence your career progression after training… it certainly was for me! In this blog, I wanted to share my thoughts about finding a consultant post, and why becoming a district general ICU consultant was the right choice for me.

During my time as a joint ICM / anaesthetic trainee, I enjoyed most of my clinical placements, so kept an open mind as to where I would work longer term. Consequently, as my CCT date edged rapidly closer, I found myself struggling to decide where I ultimately wanted to seek a consultant position. After careful consideration, I narrowed my preferences down to two hospitals – one was a large, adult-only teaching hospital and major trauma centre; the other a district general hospital (DGH) with a considerably smaller 11-bedded critical care department.  

They seemed like polar opposites, offering very different prospects. I spent months languishing over the possible consequences of making the ‘wrong’ decision. During training lists, I would often receive well intended (though frequently unsolicited!) opinions about where I should, and shouldn’t, apply; whilst I was very appreciative of the interest shown in my career plans, someone else’s personal beliefs couldn’t really reflect what would be right for anyone other than themselves.

So, I considered what factors were most important to me – I spoke to family, and to friends recently appointed into posts who had experienced similar dilemmas. I decided: what mattered most to me was who I would be working with – I wanted to be part of an enthusiastic, dynamic and friendly team, which I could contribute to, and whom I could go to for support (and to ask the inevitable torrent of ‘newbie’ questions I would have once I started!).

Ultimately, I applied for a position in the district general hospital, where I’ve now been happily working for over a year, splitting my time roughly evenly between ICM and anaesthesia. Being a smaller department, our ICU consultant team is very much hands on – although we have a range of trainees joining us from anaesthesia, ICM, ED and medicine, there’s still plenty of work to go around. This means I get the opportunity to insert chest drains, tracheostomies and similar, fairly frequently – this not only helps me to keep up my practical skills, but it’s also pretty enjoyable and often an ideal teaching opportunity!

Having fewer patients allows us to get to know them and their families very well, and we have the time to personally undertake detailed assessment of their condition. This is not only highly rewarding, but also helps to individualise patient care. Similarly, having fewer staff within the hospital means that it doesn’t take long before you get to know most of your colleagues within and outside your specialty; this familiarity can make a substantial difference to the ease of your day-to-day functioning, particularly when seeking specialist advice (or just a friendly face to vent to after a hard day!). It really creates a ‘family’ feel in the workplace, which can significantly influence your job satisfaction.

There are, of course, some practical limitations to being within a smaller centre, and a variability in the case mix when compared to a larger hospital. There are a number of specialties that we don’t routinely have access to on site – such as vascular and major upper gastrointestinal surgery. However, whilst we may not care for patients undergoing, for example, aneurysm repair, we do get exposed to a number of acute paediatric admissions requiring critical care input, which is something many tertiary units may not experience.

This limitation in immediately-available resources perhaps creates one of the most challenging aspects of DGH work – sometimes we are responsible for making major decisions regarding a patient’s need for specialist care (which we may not be able to provide on-site) based upon our own opinions, and that of specialist(s) who have not physically seen the patient concerned. In reality, no hospital has direct access to every specialty on a single site – it’s simply a case that DGHs must deal with this issue more frequently than other centres. Whilst this can be stressful at times, there’s great satisfaction in being able to work collaboratively and efficiently with other centres to facilitate getting patients to the right specialist care they need at the right time, regardless of whether or not you’re the team ultimately delivering it. Typically, patients will be repatriated back to our unit once this specialist input is complete, so we still get to provide that continuity of care in the longer term and follow them up after they have left the ICU.

In terms of non-clinical activities, realistically it’s often easier to involve yourself in projects and implement change within smaller units – I’ve already been fortunate enough to take on faculty tutor and clinical supervision roles, lead weekly ICU trainee teaching, and develop a Tracheostomy MDT group (as well as joining the WICMEL fellowship programme!), and I’ve felt well supported within these positions.

Of course, many of these attributes aren’t entirely exclusive to district general ICU work, but they’re aspects which I personally have found to be both challenging and enjoyable as a consultant, and can hopefully provide a little food for thought to those making decisions about their future careers. Choosing where you want to spend potentially the next 30-plus years of your working life is very much an individual decision; However, many ICM trainees will ultimately end up working within a DGH, and I hope this blog helps to highlight how hugely rewarding this can be, and the important role that DGHs play in maintaining the high standard of critical care delivered nationally.