We talk to Jim Watts, Consultant in Critical Care Medicine and Anaesthesia and JAP’s consultant editor.
JAP: As a specialist in anaesthesia, could you tell us more about your experience and training background in this field?
JW: I trained as an anaesthetist in the days when critical care was not a separate specialty, in both the North West and the West Midlands. I took up my SR post the month before they changed to run through ST training, so I can claim to be one of the last of the Senior Registrars.
My non anaesthetic training consisted of House Officer posts in Wales, and the North West; and SHO posts in paediatrics and casualty.
Even as a trainee I looked for extra curricular roles that not only stimulated my interest but which boosted career prospects. I was one of the youngest doctors recommended for a faculty position in the then fledgling ALS/APLS training, and I also held a post on the Group of Anaesthetists in Training (GAT), which meant that I became a co-opted member of the Royal College Training committee. Both of these experiences fostered an interest in teaching and training that has lasted all of my career. As a consultant, I have taken on a number of additional roles including Clinical Director, Deputy Medical Director, an advisor to NICE, Medical Examiner and I was previously an advisor to the PHSO. This has given me a broader understanding as to how the NHS works as an institution, locally, regionally and nationally.
JAP: What drove you to choose anaesthesia as a career?
JW: When I completed my House Officer years I was somewhat disillusioned with the way medicine was practiced on the wards, and I knew that I was not suited to be a GP. So I was looking for a career that was patient facing, that did not place me at the mercy of random and unjustified recurrent calls, but which would allow me to develop my diagnostic and technical skills. In those days, it was legitimate to sign up to a year’s worth of anaesthetic practice, at the end of which you could sit the Diploma in Anaesthesia –now known as the part 1 exam. Within days, I knew I had made a great choice. This was the ‘real-time’ specialty I had been looking for, which would give me the breadth and depth of practice that would allow me to develop my clinical acumen, and to learn new technical skills.
Anaesthetists remain the most skilled generalist in the hospital, very experienced at an early stage in their career at recognising and treating the seriously ill, while retaining a high level of appropriate hands-on consultant supervision. In addition, the challenge of critical care remained fascinating: a related, but different set of skills to optimise the treatment of the chronically critically ill
JAP: As we head in 2021, it is clear that the healthcare industry has been greatly impacted by this year’s events, what has been the greatest impact within the anaesthesia industry?
JW: I think the need to develop CPAP/Nasal high flow/ CPAP as a ward based therapy, which means finding the equipment (hopefully now in plentiful supply) and addressing training issues in nursing and medical staff, and developing ward based facilities.
We have also seen an unprecedented expansion in Critical Care facilities, and hopefully this extra bed base will be maintained, funded and supported to enable us to accommodate more complex surgery and unwell patients.
The main lesson of 2020 though is that we have been reminded what a world without antibiotics looked and felt like. We forget that antibiotics have only been around for a relatively short period, and that microorganisms are becoming increasingly ineffective. Hopefully there will be an increasing focus on correct antibiotic stewardship, and a recognition that this is the responsibility of everyone: medical and nursing staff, politicians, agriculture and vetinary medicine.
JAP: What’s the best part of your job?
JW: The best part of an anaesthetist’s job is being able to provide a quality experience to a patient from the start to the finish of their surgical journey.
There is no such thing as just a “quick GA”. Every anaesthetic is a risk, and every technique must be individualised to the patient. Whether it is for a day case procedure, or lengthy complex cancer surgery, being able to ensure that the patient emerges in the best condition-oxygenating, pain free, physiologically stable-to give them the best chance to benefit from the surgery is the best feeling.
It is similar in ITU: our role is to achieve physiological stability giving the patient the best chance to get better from their underlying pathology. As a bonus, you can sometimes address other problems that the patient has acquired, such as social issues or chronic pain.
JAP: … and the worst?
JW: The number of people who believe they can tell me what my job is, or the belief that my ability to sort out a difficult situation is in some way approval of what has gone before.
JAP: What has been the highlight of your career so far?
JW: So many highlights, but being able to redesign and modernise an ITU with a team of managers, nurses and medical colleagues in my first few years as a consultant has to be in the top five. In a way, the COVID epidemic has also reintroduced the concept of teamwork, and focused us on wellbeing of the whole staff as important to patient care.
JAP: Are you currently involved in any scientific research within your work?
JW: As a unit we are involved in many of the trials in relation to COVID, and have been successful in recruiting many patients. I was personally involved with advising NICE on some of their rapid evidence reviews, and authored-or co-authored- some chapters for the RCoA audit recipe book.
JAP: If you weren’t an anaesthetist what would you be?
JW: Some kind of scientist. Or perhaps a historian.
JAP: What would you tell your 21-year-old self?
JW: Learn to play a musical instrument
JAP: If you were Health Minister for the day what changes would you implement?
JW: Assuming I could not pour money into the health service, I would abolish the wasteful and expensive internal market system, and increase standardisation of care; defining better what the health service is for, and, more importantly, what it is not for.
JAP: Away from the clinic and operating theatre – what do you do to relax?
JW: Amongst many things, I go to the Lake District to unwind. I also write. I am interested in history, and recently wrote and published a book with my son, called ‘The Cottontown Killer’, the real life tale of the hunt for a murderer (available on Amazon). Hopefully, it will be an interest I can develop.
JAP: How do you think the future looks in the field of anaesthetics and patient experience and what are your predictions for 2021?
JW: I think the future may be more appreciative of anaesthesia and ITU than it has been in the past.
Firstly, the Prime minister has seen how complex, challenging and important critical care is first hand and it is possible that this may benefit health care funding as a whole, and critical care provision specifically.
Secondly, we have been able to expand critical care capacity at relatively short notice, generally doubling it across the UK. It is certain that the majority of this capacity will be retained, and that this will have beneficial effects on emergency and elective patient workload, providing that we can retain staffing levels without pulling back from the high standards that were previously recommended.
Thirdly, many consultants moved onto full shift systems temporarily, moving away from the 24-hour on call system that still clung on in some places. Given that dinosaurs like myself who prefer that system will be retiring in a few years, it is unlikely that we will ever go back to it. However, shifts have their own challenges, such as the amount of down time a consultant will get following a night shift, reducing their ability to be available during “office hours”. This will have to be a stimulus to recruitment, but is likely in the short term to place pressure on the current contract and “SPA time”. As extra training was provided to “pure anaesthetists” who backfilled into critical care roles it is possible that dual qualified intensivists may even counter-pressure for more SPA time. It is also possible that intensivists will as a result become less available for non-ITU tasks.
There may well be an effect on the type of patients admitted to ITU or the type of treatment they are admitted for. However, there will be an effect on the way in which patients ventilated for lung disease will be managed. COVID has taught us a lot about atypical lung mechanics, V/Q ratios and other physiology. It is possible that we will adapt this to other lung pathologies, and that ventilator strategies will be concerned with mechanics rather than achieving set oxygen or CO2 levels.