Introduction
My name is Ishwinder Thethy, and I am a Consultant Physician in Acute and General Medicine, at the Royal Infirmary of Edinburgh. I studied medicine at the University of Edinburgh, and did my post-graduate training in the SE Scotland Deanery, CCT’ing in 2016. I am also the Training Program Director for Internal Medicine Training Stage 1 in the SE Scotland Deanery.
Those who know me well would use the word ‘non-conventional’, with a generous sprinkling of comedy, to describe me – born more so out of necessity than conscious choice.
What got you interested in Syncope as a special interest?
‘Man plans and God laughs’ – a good colleague once exclaimed to me. During my post-graduate training I actually sub-specialised in Medical Education. Syncope was far from my conscious pursuits. When I took up my consultancy, I inherited a free for all General Medical clinic, in which patients with Syncope of unknown cause were being referred for assessment, amongst others (e.g., a hydrocele) – ‘God laughs indeed.’ Flying by the seat of my pants was not going to do this justice. I, therefore, had to up-skill – in syncope (not urology) – post CCT, as described below.
How did you train in syncope and what other avenues are there?
During my post-graduate training, I had assessed some patients presenting with syncope at the front door. I recall attending an Acute Medicine National Training Day when I first heard Dr Lara Mitchell, Physician, who set up the syncope service in Greater Glasgow & Clyde, do a talk on the subject.
When I inherited my General Medical clinic, post CCT, I took the following steps to up-skill:
- I contacted Dr Mitchell and sat in on her Syncope clinic in Glasgow, and her Syncope multidisciplinary team meeting. She generously allowed me access to local protocols to adapt locally in Lothian, which I did.
- I attended an intensive course in Newcastle on Assessment of Syncope, Falls and Dizzy Spells
- I collaborated with my local Cardiology, Emergency Medicine and Neurology colleagues and revised the Front Door Syncope Assessment protocol
- I ensured my practice was in keeping with the European Society of Cardiology Guidelines on Syncope
I eventually set up a syncope clinic in NHS Lothian, within the remit of the General Medical Clinic. With the help of a friendly Cardiologist and Neurologist, I have managed to ensure complex patients have relevant sub-specialist input.
I continue to strive to standardise the assessment and management of Syncope, in keeping with guidelines, in my locality.
What challenges did you face?
There were no dedicated syncope clinics or a syncope service as such in the SE Scotland. In my local trust, NHS Lothian, convincing interested parties and hospital management that a dedicated Syncope standardised service is required was challenging.
Formalising a dedicated MDT approach to assessment of patients has also been a challenge. This needs to be established within contract pending further negotiation.
How does this fit into your consultant working?
I have one session for the General Medical Clinic (weekly clinic) and have managed to ensure that most patients are those presenting with high risk syncope, normal ECG and unknown cause. There is an StR clinic running alongside it, for anyone interested.
Do you have any tips for trainees who may be interested in syncope as a special interest?
Sub specialising in Syncope Assessment is a rewarding skill.
I particularly enjoy the multidisciplinary discussions and close collaboration with my cardiology & neurology colleagues. It adds value to my knowledge, skills and attributes in interpretation of complex cardiac physiology and rhythm disturbances. I enjoy the challenge and continue to learn.
Syncope is a common presentation to Emergency Departments, with 50 per cent of patients going undiagnosed, and a high incidence of adverse outcomes. To have expertise in diagnosis and assessment of syncope will not only make patient journey better and safer but will add expertise to your unit.
My advice to trainees wishing to sub-specialise in this would be to pursue the following avenues:
- Have a dedicated session in your roster to attend local Syncope Clinic and MDT discussions, and cardiology clinics on rhythm disturbances, if possible
- Consider attending the New Castle Course on Syncope, Falls and Dizzy Spells
- Attend Syncope Conferences when possible
- Refresh knowledge on ESC guidelines for Syncope
The following resources are also valuable to consult when assessing syncope patients:
If you are interested and would like some pointers, please do get in touch.
‘Two roads diverged in a wood, and I – I took the one less travelled by, and that has made all the difference’ – Robert Frost
