Is a Single Entry Training Scheme for Intensive Care Medicine Both Inevitable and Desirable?* Anthony S. McLean, MBChB, BSc(Hons), MD, FRACP, FCICM, FCSANZ1,2 Abstract: The development of Intensive Care Medicine as a recognizable branch of medicine has been underway for more than half a century, with delivery by a number of different service models. This delivery may be entirely by related medical specialties, such as anesthesiology or pulmonology; alternatively, it may be as a standalone-recognized specialty and frequently by a hybrid of these two extremes. A country may have a completely different delivery model from neighboring countries, and different models may exist within a single country. Debate about the most appropriate method of providing critical care services frequently centers around the training. However, an alternative perspective is that training regimes only follow on from another objective, namely to have Intensive Care Medicine represented in important forums by dedicated critical care physicians. A historical perspective of the development of critical care in two countries over a 40-year period is discussed, whereby a transition from a multiple specialty provision of critical care medicine to that of a single binational pathway occurred. The perceived advantages and disadvantages are outlined, offering insights into how possible future challenges in a highly complex medical specialty can be anticipated and strategies formulated. (Crit Care Med 2015; 43:1816–1822) Key Words: critical care medicine; Intensive Care Medicine; medical specialization; training programs
I
ntensive Care Medicine (ICM) has its origins in the development of prolonged mechanical ventilation support to individual patients, providing a mechanism to enhance survival in conditions such as poliomyelitis. Thus, it was initially a ventilation support service, creating the situation where it became recognized as an adjunct to other medical specialties, *See also p. 2020. 1 Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia. 2 Nepean Clinical School, University of Sydney, Sydney, Australia. Dr. McLean is employed by the Nepean Hospital. His institution received support for travel from Nepean Institute Critical Care Education and Research. For information regarding this article, E-mail: [email protected] Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001088
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commonly a primary pulmonology or anesthetic subspecialty. In some countries, the nomenclature used was Critical Care Medicine, and for the purposes of this article, the two terms are used interchangeably. As a relative new medical specialty with an increasingly broad mandate, the subsequent evolution has varied from country to country largely due to the differing pathways by which medical specialization occurred. Indeed over the past 60 years in which ICM first began, these associated medical specialties have also developed considerably, often including ICM as an integral part of their own practice. From the first step as a ventilation support service, ICM gradually absorbed other life support activities, perhaps best described by the French term “reanimation,” the inference of pulling a life back from the brink of certain death. Such practices, once extraordinary, are now routine in modern day intensive care practice and include hemodynamic support, renal replacement therapy, management of an unexpected imminent death, countering severe hemorrhage—to name a few. Accompanying this tremendous role amplification is staff training requirements, including not only doctors but also nurses and other support staff groups in a shared goal of providing optimal care to the critically ill patient and their families and friends. A focus on medical ICM training has gathered momentum over the past few decades, and with it the realization of how varied such training is, not only between different countries but often within individual countries. Other medical specialties often claim ownership of ICM within their parent specialty, and interspecialty communication or cooperation to identifying mutual acceptable standards of training exists in some countries, but not others. A contrary approach has occurred in a few countries, where all ICM training, certification, and credentialing are only available through a single dedicated scheme, unrelated to other medical specialties. Considerable international variation in training programs has been documented (1, 2). This proposal supports the notion that progression to a single training scheme for ICM may be desirable and, over time, inevitable. It uses a specific example of a national single training scheme that has evolved to support the notion of this progression. The proposal argues that a single training scheme is desirable to provide optimal training and inevitable because of the aspiration by which ICM asserts itself as an independent representative in multiple forums, including political, administrative, medical, and academic. September 2015 • Volume 43 • Number 9
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Feature Articles
CHRONICLE OF AN ILLUSTRATIVE CASE STUDY The ICU came into evidence in 1970s in Australia and New Zealand, with certain individuals identified as being committed pioneers in the field (3). A number of medical specialties permitted or even encouraged selected doctors to practice predominantly within these units. Others shared their working time between their base specialty and the ICU. By the late 1970s, both the credentialing bodies for physician and anesthetic specialist training, the Royal Australasian College of Physicians (RACP) and the Royal Australasian College of Surgeons: Faculty of Anaesthetics, created dedicated programs for ICM training as a subspecialty. This decision permitted and encouraged double qualifications to allow a mixed practice. At that time, some perceived that ICM was physically, emotionally, and mentally too demanding for an individual to practice through their entire working life, with anticipated reversion to a more gentle base specialty practice by middle age. Practitioners from base specialties other than anesthesia or medicine, such as surgery, were permitted, but as their training bodies did not provide specific training programs for ICM, the number of such practitioners decreased over time. An important parallel process was the creation of a single unified Intensive Care Society, the Australian New Zealand Intensive Care Society (ANZICS), a body that played a pivotal role in the push for a single training scheme. The first Annual General Meeting of ANZICS was held in 1975, and ANZICS from that time onward was a vehicle for the establishment of ICM (4). Even though it was not directly involved in specialist training, it provided a forum whereby intensivists from all backgrounds met regularly. It organized national annual scientific meetings and became the impetus for other creative developments in ICM. ANZICS by its mere existence, as well as its activities, highlighted the unique nature of ICM, and a practitioner found he/she usually had much more in common with fellow critical care physicians then they did with colleagues from their parent specialty. This was despite the parent colleges often conveying the impression of superiority of their intensive care training program over those of other colleges. A parallel important hospital systems practice was also gradually evolving that by which all intensive care beds were geographically located in one area, breaking down the silo mentality of different groups running ICUs in different parts of the hospital. This trend was driven as much by financial efficiencies than by professional necessity but still had the effect of grouping intensivists together, regardless of their parent specialty. This evolution was accompanied by much debate and discussion, often vociferous, with adherents to the traditional methods not wishing to embrace any weakening of parent college ties, while others saw ICM in a similar light to other emerging independent specialties such as Emergency Medicine and Family Medicine. The debate continued throughout the latter part of the 20th century and early into the 21st century. By the 1980s, the niggling differences between the two training schemes, such as the presence/absence of an exit examination, resulted in 1996, in the creation of a Joint Specialist Advisory Critical Care Medicine
Committee for ICM with purpose of producing a common standard for ICM training (Fig. 1). From this initiative, the Joint Faculty of ICM was born in 2002, with representatives from RACP, the Australian New Zealand College Anaesthetists, and ANZICS on the governing board. It was notable that the anesthetic community had also previously followed a similar path, separating from the Royal Australasian College of Surgeons and becoming an independent body in 1992. This recently acquired independence was most likely a factor in making them reluctant to “lose” ICM from their new body. Interestingly, this joint faculty widened the door to prospective trainees, allowing candidates who had passed their entry examinations for Emergency Medicine and Surgery to also enter the Intensive Care program. Over the following decade, the faculty consolidated ICM training and in combination with ANZICS gradually became the predominant voice in matters relating to the specialty. By 2010, the faculty was dealing with all training issues, becoming professionally independent of the parent colleges, and the inevitable final step to an independent training body occurred, ties with the parent colleges of physicians and anesthetists being amicably severed. The College of Intensive Care Medicine (CICM)–Australia and New Zealand was born and now is the predominant representative body for the specialty in Australia and New Zealand. The training program has continued to evolve, with a 6-year minimum training period, entry and exit examinations, a compulsory year of internal medicine, and another for anesthetics (5, 6) (Fig. 2). Recent changes reversed the broader entry model with entry now being restricted to success in the entry examination created by CICM, thereby denying direct admission from other training schemes early in the program (7). Pediatric ICM training follows a similar format to that of adult ICM, but with 18 of the 24 months of mandatory advanced intensive care clinical training being in an accredited PICU. The primary examination is the same as for both adult and pediatric trainees, but the second, or fellowship examination, is a dedicated pediatric one. The trainee also requires a year of general medicine (pediatric) and anesthetics (pediatric or combined adult/pediatric). Neonatal ICM is not covered by CICM but occurs via the RACP, within the Division
Figure 1. Evolution of intensive care medical specialty training in Australia and New Zealand. ANZCA = Australian New Zealand College Anaesthetists, ICM = Intensive Care Medicine, CICM = College of Intensive Care Medicine, JFICM = Joint Faculty Intensive Care Medicine, RACP = Royal Australasian College of Physicians, RACS = Royal Australasian College of Surgeons. www.ccmjournal.org
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alone should represent ICM at the multiple forums so necessary in any complex health system. This notion, not training, was the primary imperative. This particular objective was partially achieved with ANZICS, but as this body did not undertake training, representation in various forums dealing with the practice of ICM in Australia and New Zealand occurred with representatives of the parent colleges. Intensivists wished for negotiations with employing hospitals, state health departments, Federal government bodies, and in regard to remunerations issues with private healthcare providers, to be directly with them. Only an ambition three decades ago, this objective is now current practice in all forums. The training program development essentially had to follow the direction of this professional independence agenda. The blending of representation issue and training has now reached the situation where CICM qualifications, or equivalent, are necessary for appointment to an ICU position at any medium or large hospital in Australia.
COMPARATIVE CRITICAL CARE TRAINING IN REGIONAL ASIAN COUNTRIES Australia and New Zealand are geographically located in the Asia-Pacific region, a region abounding with a diversity of other countries. They both by necessity interact with these countries on a number of fronts, including cultural, social, sporting, and economic. Combined ICM meetings are not uncommon, and a nascent umbrella organization, the Asia Pacific Association of Critical Care Medicine, exists. The region exhibits a great variety with some countries having a population of less than a 100,000 people, while at the other extreme of the spectrum, China has more than 1,300 million people. The economic spread is also very broad; however, the trend is toward increasing affluence
Figure 2. College of Intensive Care Medicine (Australia and New Zealand) Training Program Outline. ICM = Intensive Care Medicine.
of Paediatric and Child Health. This involves 3 years of basic pediatric training followed by three advanced years of neonatal/perinatal medicine.
DUAL OBJECTIVES Although the international debate tends to focus around “single” versus “multiple” entry training programs for ICM, it could be argued that a more important incentive for those early agitators of an independent specialty was that intensivists 1818
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Feature Articles
in the region generally. ICUs range from rudimentary services to large sophisticated services, the equivalent of any found in Europe, North America, or Australia. ICM specialist training programs are evolving rapidly, and many of the concerns that rose above, such as seeking independence from parent medical specialties, have a resonance among many fulltime critical care physicians. Different countries have different training schemes, but the great majority have multiple specialty entry, with only Hong Kong having a single entry training scheme, in addition to multiple entry ones (Table 1).
a need for a base-up approach by national societies to force a pan European agenda to create ICM as an independent specialty. Conversely, Van Aken et al (9) argued that ICM must remain multidisciplinary for the following reasons: 1) it is too complex for a single specialty, 2) as a single specialty it would impede collaboration, 3) ICM is too demanding physically and emotionally fulltime, and 4) another specialty is important for “time-out” or probable “burn-out” from ICM. These individual points of debate, including others that become apparent with a single entry program, are reviewed below.
PIVOTAL ISSUES IN THE SINGLE VERSUS MULTIPLE ENTRY TRAINING SCHEMES DEBATE
Complexity ICM is one of the most complex medical specialties, not only in regard to the diverse pathologic conditions that are dealt with but also linked issues, such as dealing with death and dying, medicolegal implications of sudden unexpected illness/ trauma, organ donation, integrating different professions in a cooperative approach to the patient, and the need to collaborate with external medical teams. All these factors can be
The debate on how to best develop ICM in an effort to cope with present and future demands appears to have created two major opposing camps among practitioners, exemplified by recent European publications. Rubulotta et al (8) lamented that ICM is not a mother specialty in Europe, and there was Table 1.
Comparison of Intensive Care Medicine Training Programs in Asia
Country
Medical School
Mandatory General Hospital Appointment Years
Malaysia
5
3
Anesthesia, internal medicine, surgery, emergency medicine
4
3
+
+
Taiwan
7
3
Anesthetics, internal medicine, cardiology, pulmonology, surgery, emergency medicine
2
2
+
+
Korea
6
5
Internal medicine, emergency medicine, anesthesia, neurosurgery
2
1
+
+
Japan
4
2
Cardiology, internal medicine, anesthesia, emergency medicine, surgery
2
2
–
+
Indonesia
6
2
Anesthesia, pediatrics, surgery, internal medicine
4
2
+
+
Thailand
6
3
Internal medicine, anesthesia, surgery
3
2
+
+
Hong Kong
5
1
Anesthesia, internal medicine, intensive care medicine
6
2
–
–
4–6
1
6
+
+
Australia/ New Zealand
Primary Speciality
ICM
Duration
—
ICM Duration of Training
Common ICM Exit Program Examination
ICM = Intensive Care Medicine, + = present, – = absent/none. All numbers indicate by years.
Critical Care Medicine
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McLean
defined and formally included into a training scheme. The proposal that ICM is too complex for a single specialty raises a major reasoning flaw. If all the relevant issues are not included in a trainee’s program, the assumption is that perceived deficits in patient care are dealt with by one’s multidisciplinary ICM colleagues. Yet in an average sized ICU, it is difficult to see how all relevant major organ systems can be covered by independent experts in each and every system. Training Demands Achieving clinical competency in all core areas is a requirement of a single entry training scheme, since an individual intensivist is expected to deal with a critically ill patient with a broad range of underlying illnesses at any time during the day or night, from neurosurgical, infectious diseases, severe cardiac failure, acute respiratory distress syndrome, and acute renal failure—to name only some. The resulting training program is demanding and much longer in duration than that expected in the “sub/supraspecialty” model. Following at least 1 year of general hospital experience postgraduation from a basic medical degree, the Australian/New Zealand program takes a minimum of 6 years. This time includes intensive care medical training in addition to 1 year each of anesthesia and medicine. Assessment has to be comprehensive to ensure only fully competent holistic intensivists advance to specialist positions in hospitals. This demanding training program has obvious organizational, logistical, and financial implications. Collaboration The statement that a single entry training scheme would impede collaboration is a curious claim since every day working within an ICU brings a need for frequent collaboration at all levels: patients, relatives, nursing staff, paramedical staff, and administrators, in addition to a myriad of our medical specialist colleagues, both junior and senior. Indeed, ICM is an environment where the intensity and frequency of communication is matched by few other areas within medicine. Certainly, if one’s ICM colleagues have, for example, a cardiology background, that may ease the burden of understanding of a specific cardiology problem, but helps little with hematological, infectious, and other problems. Need for a Back-Up Specialty The claim often made is that clinical ICM is too demanding physically and emotionally to undertake continuously. An extension of this theme is that older doctors would wish to sidestep into an alternative calmer and less demanding specialty 1 day and hence the need for double specialization. Experience in Australia/New Zealand has been quite contrary to this expectation. A more dedicated and cohesive ICM fraternity resulted in more civilized staffing arrangements, whereby clinical time is interspersed with important nonclinical activities, such as training, quality/safety, research, plus participating in administrative matters elsewhere in the hospital or university (where ICM requires a voice). The great majority of major ICUs are located in the public hospital system and salaried 1820
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positions predominate. The alternative fee-for-service model, where present, can limit the nonclinical contribution by specialists on financial grounds. The anticipated “early retirement from clinical ICM” has not occurred, with the majority of specialists eschewing their alternative specialty to remain in the world of ICM. Ironically, this behavior, combined with a recruitment evolution, has resulted in another completely unexpected challenge for ICM, as will be further explained in the next section. Recruitment In contrast to reports in the international literature raising major concerns about attracting a sufficient number of doctors into the specialty, raising the profile of ICM as a medical specialty in its own right, combined with retention of practicing intensivists until they retire from medicine, has resulted in an impending oversupply of specialists in Australia/New Zealand. This unexpected turn is attracting attention because unlike other medical specialties, the demand side is restricted by the requirement for highly sophisticated, costly locations within medium to large hospitals. Although the concept of an “ICU without walls” may produce some additional positions, the great majority of trainees desire a traditional ICM specialist position. The implications of this unexpected surplus have yet to be worked through. A recent survey of newly graduated CICM fellows between the years 2010 and 2012 found that 80% of responders were employed as intensivists, 70% in full time ICM positions, and 75% obtained jobs within 6 months of graduation (10).
PERCEIVED CHALLENGES WHEN A SINGLE ENTRY SCHEME IS ADOPTED Concerns do exist from the perspective of the author, a participant and observer of the evolution from multiple entry system to a single entry training scheme. Observations over many years bring the salutary lesson that this process is never fully completed, and every generation must strive to improve training in a continually changing environment. Comprehensive Training Program to Cover Core Competencies Opinions may differ as to what exactly should be included as mandatory components in the training of an intensivist, but all would agree that a broad range of competencies are necessary. Any training program would thus be demanding in terms of time and intensity of study. Assessment of competency to commence specialist work becomes a major undertaking of practical aspects of training and theoretical evaluations. Inability to Incorporate Research Training and Science During Training Years There is an intense emphasis on training and passing examinations, resulting in a candidate investing all his/her energies into the process. This does not allow time for other activities, very relevant to the future of ICM. Some understanding of research is attempted with a mandated “project,” but limited September 2015 • Volume 43 • Number 9
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Feature Articles
time negates a more comprehensive involvement. For example, it becomes very difficult to attract bright young minds into formal research or PhD programs, not only during training but following successful completion of their clinical qualification. Once finishing their training, newly qualified specialists understandably seek respite from additional study and further examinations. Unidimensional Graduates In the early stages of setting up a single entry training program, there is a risk in too closely defining the training process, resulting in producing very similar graduates. Training standards becomes defined by a small group of persons involved in the institute responsible, where enthusiasm and dedication do not always mix with vision and wisdom. In the past, and in the present, ICM has benefited greatly by the colorful range of competent practitioners who brought different ideas from a variety of backgrounds to daily practice and to scientific meetings. Balancing Attainment of Acceptable Standards With Fairness This challenge is best exemplified by the inability of a trainee, who after 6 years of training has difficulty in passing the exit examination. Where does this person go professionally if the examiners believe the candidate does not achieve the required standard? The contrary situation is to ensure that all pass the exit examination, but this indicates a lack of discrimination between those who are sufficiently competent to proceed to specialist practice and those who are not. Therefore, identification of a candidate who is unlikely to succeed needs to occur earlier in the training program, allowing them to pursue an alternative course and not waste many years in a scheme that brings no ultimate professional benefit. Recent changes to the training program with regular formative and summative interviews with college appointed supervisors of training being strengthened may redress this problem.
INFLUENCE OF ESTABLISHING ICM AS AN INDEPENDENT SPECIALTY IN UNIVERSITY MEDICAL STUDENT PROGRAMS Medical student engagement in ICM is variable across the world, and this variation exists even within an individual country. Although universities may be responsible for both basic and advanced medical training in some countries, in others, medical student training and specialist training programs are separated. The latter situation exists in Australia and New Zealand, where the universities are responsible for the former and specialist medical colleges the latter, and although ICM in actual practice is now an independent medical specialty, this is not necessarily reflected in the curriculum of medical schools. A recent survey found that 60% of medical school programs included mandatory training in ICM, but the extent was varied and usually occupied only a very small portion of the overall curriculum (11). Even more revealing was the limited importance of the subject whereby a rigorous evaluation of a student’s engagement was Critical Care Medicine
lacking, to the point where it made little impact on whether the student progressed or not. Interestingly, the survey provided insight into what defines ICM, by questioning what it provides in the medical curriculum that other medical specialties cannot, that is, what is unique about ICM? The survey responses reflected uncertainty among intensivists as to what constitutes ICM, or more specifically what can the speciality offer in training medical students that is not adequately provided by other medical specialities. Further engagement with the universities is imperative for the development of ICM. Australian surveys have found that 20% of medical students had selected their specialty of choice by the end of medical school and a further 16.7% by the end of their first postgraduate year (12, 13). If ICM is to attract the brightest and most promising of the graduates, these figures are a sober reminder that exposure needs to occur early in the young doctors’ career.
CONCLUSIONS The debate on whether ICM should be an independent medical specialty or alternatively a super/subspecialty of multiple other medical specialties generally has a focus on training programs. In the opinion of the author, the major driving force is a desire to have ICM seen and act independently, albeit in cooperation with other specialty consultants. This is an imperative if we as a profession are to manage the challenges that face us, in order to provide optimal care to our patients. More cohesive training programs by necessity follow this move to independence. Experiences in those domains that have already adopted single entry training programs demonstrate that many of the concerns raised by those opposing such a move do not eventuate. However, other concerns unfold, some unexpected, some not. Such concerns include attracting the most innovative doctors to ICM while not creating training programs that stifle initiative, nurturing future leaders of the profession, and balancing training capacity with workforce requirements. In an ever changing healthcare environment, future unknowns will inevitably accompany the evolution of ICM as a proud and progressive medical specialty, rising to future challenges of a society expecting first-class medical care. Challenges pertinent to ICM include fiscal responsibility in providing an expensive service, moral responsibility in determining who should receive complex therapy and who shouldn’t, identifying the boundaries of our practice both within and without the ICU, balancing the forces of evidence-based medicine with practical intuitive care, maintaining cooperative relationships with other groups within the hospital, and managing ever increasing and complex technology. Wisdom is required to manage the delicate balance between guidance and control.
REFERENCES
1. Gupta R, Zad O, Jimenez E: Analysis of the variations between Accreditation Council for Graduate Medical Education requirements for critical care training programs and their effects on the current critical care workforce. J Crit Care 2013; 28:1042–1047 2. Barrett H, Bion JF: An international survey of training in adult intensive care medicine. Intensive Care Med 2005; 31:553–561 www.ccmjournal.org
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McLean 3. Trubuhovitch R, Judson J: Intensive Care in New Zealand—A History of the New Zealand Region of ANZICS. New Zealand, Department Critical Care Medicine, Auckland Hospital, 2001 4. Phillips G, Trubuhovitch R: A Record of Events: The First 25 Years 1975–2000. ANZICS, Department of Critical Care Medicine, Auckland Hospital, Auckland, 2001 5. Freebairn R: College of intensive care medicine in the antipodes. ICU Manage 2014; 14:42–44 6. College of Intensive Care Medicine: Training Program 2014. Available at: http://www.cicm.org.au/Trainees/Program/2014-Program. Accessed April 30, 2015 7. Bevan R, Freebairn R, Lee R: College of Intensive Care Medicine: Changes to intensive care medicine training. Crit Care Resusc 2014; 16:291–293 8. Rubulotta F, Moreno R, Rhodes A: Intensive care medicine: Finding its way in the “European labyrinth.” Intensive Care Med 2011; 37:1907–1912
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9. Van Aken H, Vallet B, Mellin-Olsen J: Comment on Rubulotta et al: Intensive care medicine: Finding its way in the “European labyrinth.” Intensive Care Med 2012; 38:1074–1075; author reply 1076 10. Venkatesh B, Freebairn R: Assessment of the distribution and professional roles of the new Fellows of the College of Intensive Care Medicine of Australia and New Zealand. Crit Care Resusc 2013; 15:327–328 11. Whereat SE, McLean AS: Survey of the current status of teaching intensive care medicine in Australia and New Zealand medical schools. Crit Care Med 2012; 40:430–434 12. Joyce CM, Stoelwinder JU, McNeil JJ, et al: Riding the wave: Current and emerging trends in graduates from Australian University Medical Schools. Med J Aust 2007; 186:309–312 13. Harris MG, Gavel PH, Young JR: Factors influencing the choice of specialty of Australian medical graduates. Med J Aust 2005; 183:295–300
September 2015 • Volume 43 • Number 9
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
I
ntensive Care Medicine (ICM) has its origins in the development of prolonged mechanical ventilation support to individual patients, providing a mechanism to enhance survival in conditions such as poliomyelitis. Thus, it was initially a ventilation support service, creating the situation where it became recognized as an adjunct to other medical specialties, *See also p. 2020. 1 Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia. 2 Nepean Clinical School, University of Sydney, Sydney, Australia. Dr. McLean is employed by the Nepean Hospital. His institution received support for travel from Nepean Institute Critical Care Education and Research. For information regarding this article, E-mail: [email protected] Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001088
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commonly a primary pulmonology or anesthetic subspecialty. In some countries, the nomenclature used was Critical Care Medicine, and for the purposes of this article, the two terms are used interchangeably. As a relative new medical specialty with an increasingly broad mandate, the subsequent evolution has varied from country to country largely due to the differing pathways by which medical specialization occurred. Indeed over the past 60 years in which ICM first began, these associated medical specialties have also developed considerably, often including ICM as an integral part of their own practice. From the first step as a ventilation support service, ICM gradually absorbed other life support activities, perhaps best described by the French term “reanimation,” the inference of pulling a life back from the brink of certain death. Such practices, once extraordinary, are now routine in modern day intensive care practice and include hemodynamic support, renal replacement therapy, management of an unexpected imminent death, countering severe hemorrhage—to name a few. Accompanying this tremendous role amplification is staff training requirements, including not only doctors but also nurses and other support staff groups in a shared goal of providing optimal care to the critically ill patient and their families and friends. A focus on medical ICM training has gathered momentum over the past few decades, and with it the realization of how varied such training is, not only between different countries but often within individual countries. Other medical specialties often claim ownership of ICM within their parent specialty, and interspecialty communication or cooperation to identifying mutual acceptable standards of training exists in some countries, but not others. A contrary approach has occurred in a few countries, where all ICM training, certification, and credentialing are only available through a single dedicated scheme, unrelated to other medical specialties. Considerable international variation in training programs has been documented (1, 2). This proposal supports the notion that progression to a single training scheme for ICM may be desirable and, over time, inevitable. It uses a specific example of a national single training scheme that has evolved to support the notion of this progression. The proposal argues that a single training scheme is desirable to provide optimal training and inevitable because of the aspiration by which ICM asserts itself as an independent representative in multiple forums, including political, administrative, medical, and academic. September 2015 • Volume 43 • Number 9
Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Feature Articles
CHRONICLE OF AN ILLUSTRATIVE CASE STUDY The ICU came into evidence in 1970s in Australia and New Zealand, with certain individuals identified as being committed pioneers in the field (3). A number of medical specialties permitted or even encouraged selected doctors to practice predominantly within these units. Others shared their working time between their base specialty and the ICU. By the late 1970s, both the credentialing bodies for physician and anesthetic specialist training, the Royal Australasian College of Physicians (RACP) and the Royal Australasian College of Surgeons: Faculty of Anaesthetics, created dedicated programs for ICM training as a subspecialty. This decision permitted and encouraged double qualifications to allow a mixed practice. At that time, some perceived that ICM was physically, emotionally, and mentally too demanding for an individual to practice through their entire working life, with anticipated reversion to a more gentle base specialty practice by middle age. Practitioners from base specialties other than anesthesia or medicine, such as surgery, were permitted, but as their training bodies did not provide specific training programs for ICM, the number of such practitioners decreased over time. An important parallel process was the creation of a single unified Intensive Care Society, the Australian New Zealand Intensive Care Society (ANZICS), a body that played a pivotal role in the push for a single training scheme. The first Annual General Meeting of ANZICS was held in 1975, and ANZICS from that time onward was a vehicle for the establishment of ICM (4). Even though it was not directly involved in specialist training, it provided a forum whereby intensivists from all backgrounds met regularly. It organized national annual scientific meetings and became the impetus for other creative developments in ICM. ANZICS by its mere existence, as well as its activities, highlighted the unique nature of ICM, and a practitioner found he/she usually had much more in common with fellow critical care physicians then they did with colleagues from their parent specialty. This was despite the parent colleges often conveying the impression of superiority of their intensive care training program over those of other colleges. A parallel important hospital systems practice was also gradually evolving that by which all intensive care beds were geographically located in one area, breaking down the silo mentality of different groups running ICUs in different parts of the hospital. This trend was driven as much by financial efficiencies than by professional necessity but still had the effect of grouping intensivists together, regardless of their parent specialty. This evolution was accompanied by much debate and discussion, often vociferous, with adherents to the traditional methods not wishing to embrace any weakening of parent college ties, while others saw ICM in a similar light to other emerging independent specialties such as Emergency Medicine and Family Medicine. The debate continued throughout the latter part of the 20th century and early into the 21st century. By the 1980s, the niggling differences between the two training schemes, such as the presence/absence of an exit examination, resulted in 1996, in the creation of a Joint Specialist Advisory Critical Care Medicine
Committee for ICM with purpose of producing a common standard for ICM training (Fig. 1). From this initiative, the Joint Faculty of ICM was born in 2002, with representatives from RACP, the Australian New Zealand College Anaesthetists, and ANZICS on the governing board. It was notable that the anesthetic community had also previously followed a similar path, separating from the Royal Australasian College of Surgeons and becoming an independent body in 1992. This recently acquired independence was most likely a factor in making them reluctant to “lose” ICM from their new body. Interestingly, this joint faculty widened the door to prospective trainees, allowing candidates who had passed their entry examinations for Emergency Medicine and Surgery to also enter the Intensive Care program. Over the following decade, the faculty consolidated ICM training and in combination with ANZICS gradually became the predominant voice in matters relating to the specialty. By 2010, the faculty was dealing with all training issues, becoming professionally independent of the parent colleges, and the inevitable final step to an independent training body occurred, ties with the parent colleges of physicians and anesthetists being amicably severed. The College of Intensive Care Medicine (CICM)–Australia and New Zealand was born and now is the predominant representative body for the specialty in Australia and New Zealand. The training program has continued to evolve, with a 6-year minimum training period, entry and exit examinations, a compulsory year of internal medicine, and another for anesthetics (5, 6) (Fig. 2). Recent changes reversed the broader entry model with entry now being restricted to success in the entry examination created by CICM, thereby denying direct admission from other training schemes early in the program (7). Pediatric ICM training follows a similar format to that of adult ICM, but with 18 of the 24 months of mandatory advanced intensive care clinical training being in an accredited PICU. The primary examination is the same as for both adult and pediatric trainees, but the second, or fellowship examination, is a dedicated pediatric one. The trainee also requires a year of general medicine (pediatric) and anesthetics (pediatric or combined adult/pediatric). Neonatal ICM is not covered by CICM but occurs via the RACP, within the Division
Figure 1. Evolution of intensive care medical specialty training in Australia and New Zealand. ANZCA = Australian New Zealand College Anaesthetists, ICM = Intensive Care Medicine, CICM = College of Intensive Care Medicine, JFICM = Joint Faculty Intensive Care Medicine, RACP = Royal Australasian College of Physicians, RACS = Royal Australasian College of Surgeons. www.ccmjournal.org
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alone should represent ICM at the multiple forums so necessary in any complex health system. This notion, not training, was the primary imperative. This particular objective was partially achieved with ANZICS, but as this body did not undertake training, representation in various forums dealing with the practice of ICM in Australia and New Zealand occurred with representatives of the parent colleges. Intensivists wished for negotiations with employing hospitals, state health departments, Federal government bodies, and in regard to remunerations issues with private healthcare providers, to be directly with them. Only an ambition three decades ago, this objective is now current practice in all forums. The training program development essentially had to follow the direction of this professional independence agenda. The blending of representation issue and training has now reached the situation where CICM qualifications, or equivalent, are necessary for appointment to an ICU position at any medium or large hospital in Australia.
COMPARATIVE CRITICAL CARE TRAINING IN REGIONAL ASIAN COUNTRIES Australia and New Zealand are geographically located in the Asia-Pacific region, a region abounding with a diversity of other countries. They both by necessity interact with these countries on a number of fronts, including cultural, social, sporting, and economic. Combined ICM meetings are not uncommon, and a nascent umbrella organization, the Asia Pacific Association of Critical Care Medicine, exists. The region exhibits a great variety with some countries having a population of less than a 100,000 people, while at the other extreme of the spectrum, China has more than 1,300 million people. The economic spread is also very broad; however, the trend is toward increasing affluence
Figure 2. College of Intensive Care Medicine (Australia and New Zealand) Training Program Outline. ICM = Intensive Care Medicine.
of Paediatric and Child Health. This involves 3 years of basic pediatric training followed by three advanced years of neonatal/perinatal medicine.
DUAL OBJECTIVES Although the international debate tends to focus around “single” versus “multiple” entry training programs for ICM, it could be argued that a more important incentive for those early agitators of an independent specialty was that intensivists 1818
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in the region generally. ICUs range from rudimentary services to large sophisticated services, the equivalent of any found in Europe, North America, or Australia. ICM specialist training programs are evolving rapidly, and many of the concerns that rose above, such as seeking independence from parent medical specialties, have a resonance among many fulltime critical care physicians. Different countries have different training schemes, but the great majority have multiple specialty entry, with only Hong Kong having a single entry training scheme, in addition to multiple entry ones (Table 1).
a need for a base-up approach by national societies to force a pan European agenda to create ICM as an independent specialty. Conversely, Van Aken et al (9) argued that ICM must remain multidisciplinary for the following reasons: 1) it is too complex for a single specialty, 2) as a single specialty it would impede collaboration, 3) ICM is too demanding physically and emotionally fulltime, and 4) another specialty is important for “time-out” or probable “burn-out” from ICM. These individual points of debate, including others that become apparent with a single entry program, are reviewed below.
PIVOTAL ISSUES IN THE SINGLE VERSUS MULTIPLE ENTRY TRAINING SCHEMES DEBATE
Complexity ICM is one of the most complex medical specialties, not only in regard to the diverse pathologic conditions that are dealt with but also linked issues, such as dealing with death and dying, medicolegal implications of sudden unexpected illness/ trauma, organ donation, integrating different professions in a cooperative approach to the patient, and the need to collaborate with external medical teams. All these factors can be
The debate on how to best develop ICM in an effort to cope with present and future demands appears to have created two major opposing camps among practitioners, exemplified by recent European publications. Rubulotta et al (8) lamented that ICM is not a mother specialty in Europe, and there was Table 1.
Comparison of Intensive Care Medicine Training Programs in Asia
Country
Medical School
Mandatory General Hospital Appointment Years
Malaysia
5
3
Anesthesia, internal medicine, surgery, emergency medicine
4
3
+
+
Taiwan
7
3
Anesthetics, internal medicine, cardiology, pulmonology, surgery, emergency medicine
2
2
+
+
Korea
6
5
Internal medicine, emergency medicine, anesthesia, neurosurgery
2
1
+
+
Japan
4
2
Cardiology, internal medicine, anesthesia, emergency medicine, surgery
2
2
–
+
Indonesia
6
2
Anesthesia, pediatrics, surgery, internal medicine
4
2
+
+
Thailand
6
3
Internal medicine, anesthesia, surgery
3
2
+
+
Hong Kong
5
1
Anesthesia, internal medicine, intensive care medicine
6
2
–
–
4–6
1
6
+
+
Australia/ New Zealand
Primary Speciality
ICM
Duration
—
ICM Duration of Training
Common ICM Exit Program Examination
ICM = Intensive Care Medicine, + = present, – = absent/none. All numbers indicate by years.
Critical Care Medicine
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defined and formally included into a training scheme. The proposal that ICM is too complex for a single specialty raises a major reasoning flaw. If all the relevant issues are not included in a trainee’s program, the assumption is that perceived deficits in patient care are dealt with by one’s multidisciplinary ICM colleagues. Yet in an average sized ICU, it is difficult to see how all relevant major organ systems can be covered by independent experts in each and every system. Training Demands Achieving clinical competency in all core areas is a requirement of a single entry training scheme, since an individual intensivist is expected to deal with a critically ill patient with a broad range of underlying illnesses at any time during the day or night, from neurosurgical, infectious diseases, severe cardiac failure, acute respiratory distress syndrome, and acute renal failure—to name only some. The resulting training program is demanding and much longer in duration than that expected in the “sub/supraspecialty” model. Following at least 1 year of general hospital experience postgraduation from a basic medical degree, the Australian/New Zealand program takes a minimum of 6 years. This time includes intensive care medical training in addition to 1 year each of anesthesia and medicine. Assessment has to be comprehensive to ensure only fully competent holistic intensivists advance to specialist positions in hospitals. This demanding training program has obvious organizational, logistical, and financial implications. Collaboration The statement that a single entry training scheme would impede collaboration is a curious claim since every day working within an ICU brings a need for frequent collaboration at all levels: patients, relatives, nursing staff, paramedical staff, and administrators, in addition to a myriad of our medical specialist colleagues, both junior and senior. Indeed, ICM is an environment where the intensity and frequency of communication is matched by few other areas within medicine. Certainly, if one’s ICM colleagues have, for example, a cardiology background, that may ease the burden of understanding of a specific cardiology problem, but helps little with hematological, infectious, and other problems. Need for a Back-Up Specialty The claim often made is that clinical ICM is too demanding physically and emotionally to undertake continuously. An extension of this theme is that older doctors would wish to sidestep into an alternative calmer and less demanding specialty 1 day and hence the need for double specialization. Experience in Australia/New Zealand has been quite contrary to this expectation. A more dedicated and cohesive ICM fraternity resulted in more civilized staffing arrangements, whereby clinical time is interspersed with important nonclinical activities, such as training, quality/safety, research, plus participating in administrative matters elsewhere in the hospital or university (where ICM requires a voice). The great majority of major ICUs are located in the public hospital system and salaried 1820
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positions predominate. The alternative fee-for-service model, where present, can limit the nonclinical contribution by specialists on financial grounds. The anticipated “early retirement from clinical ICM” has not occurred, with the majority of specialists eschewing their alternative specialty to remain in the world of ICM. Ironically, this behavior, combined with a recruitment evolution, has resulted in another completely unexpected challenge for ICM, as will be further explained in the next section. Recruitment In contrast to reports in the international literature raising major concerns about attracting a sufficient number of doctors into the specialty, raising the profile of ICM as a medical specialty in its own right, combined with retention of practicing intensivists until they retire from medicine, has resulted in an impending oversupply of specialists in Australia/New Zealand. This unexpected turn is attracting attention because unlike other medical specialties, the demand side is restricted by the requirement for highly sophisticated, costly locations within medium to large hospitals. Although the concept of an “ICU without walls” may produce some additional positions, the great majority of trainees desire a traditional ICM specialist position. The implications of this unexpected surplus have yet to be worked through. A recent survey of newly graduated CICM fellows between the years 2010 and 2012 found that 80% of responders were employed as intensivists, 70% in full time ICM positions, and 75% obtained jobs within 6 months of graduation (10).
PERCEIVED CHALLENGES WHEN A SINGLE ENTRY SCHEME IS ADOPTED Concerns do exist from the perspective of the author, a participant and observer of the evolution from multiple entry system to a single entry training scheme. Observations over many years bring the salutary lesson that this process is never fully completed, and every generation must strive to improve training in a continually changing environment. Comprehensive Training Program to Cover Core Competencies Opinions may differ as to what exactly should be included as mandatory components in the training of an intensivist, but all would agree that a broad range of competencies are necessary. Any training program would thus be demanding in terms of time and intensity of study. Assessment of competency to commence specialist work becomes a major undertaking of practical aspects of training and theoretical evaluations. Inability to Incorporate Research Training and Science During Training Years There is an intense emphasis on training and passing examinations, resulting in a candidate investing all his/her energies into the process. This does not allow time for other activities, very relevant to the future of ICM. Some understanding of research is attempted with a mandated “project,” but limited September 2015 • Volume 43 • Number 9
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time negates a more comprehensive involvement. For example, it becomes very difficult to attract bright young minds into formal research or PhD programs, not only during training but following successful completion of their clinical qualification. Once finishing their training, newly qualified specialists understandably seek respite from additional study and further examinations. Unidimensional Graduates In the early stages of setting up a single entry training program, there is a risk in too closely defining the training process, resulting in producing very similar graduates. Training standards becomes defined by a small group of persons involved in the institute responsible, where enthusiasm and dedication do not always mix with vision and wisdom. In the past, and in the present, ICM has benefited greatly by the colorful range of competent practitioners who brought different ideas from a variety of backgrounds to daily practice and to scientific meetings. Balancing Attainment of Acceptable Standards With Fairness This challenge is best exemplified by the inability of a trainee, who after 6 years of training has difficulty in passing the exit examination. Where does this person go professionally if the examiners believe the candidate does not achieve the required standard? The contrary situation is to ensure that all pass the exit examination, but this indicates a lack of discrimination between those who are sufficiently competent to proceed to specialist practice and those who are not. Therefore, identification of a candidate who is unlikely to succeed needs to occur earlier in the training program, allowing them to pursue an alternative course and not waste many years in a scheme that brings no ultimate professional benefit. Recent changes to the training program with regular formative and summative interviews with college appointed supervisors of training being strengthened may redress this problem.
INFLUENCE OF ESTABLISHING ICM AS AN INDEPENDENT SPECIALTY IN UNIVERSITY MEDICAL STUDENT PROGRAMS Medical student engagement in ICM is variable across the world, and this variation exists even within an individual country. Although universities may be responsible for both basic and advanced medical training in some countries, in others, medical student training and specialist training programs are separated. The latter situation exists in Australia and New Zealand, where the universities are responsible for the former and specialist medical colleges the latter, and although ICM in actual practice is now an independent medical specialty, this is not necessarily reflected in the curriculum of medical schools. A recent survey found that 60% of medical school programs included mandatory training in ICM, but the extent was varied and usually occupied only a very small portion of the overall curriculum (11). Even more revealing was the limited importance of the subject whereby a rigorous evaluation of a student’s engagement was Critical Care Medicine
lacking, to the point where it made little impact on whether the student progressed or not. Interestingly, the survey provided insight into what defines ICM, by questioning what it provides in the medical curriculum that other medical specialties cannot, that is, what is unique about ICM? The survey responses reflected uncertainty among intensivists as to what constitutes ICM, or more specifically what can the speciality offer in training medical students that is not adequately provided by other medical specialities. Further engagement with the universities is imperative for the development of ICM. Australian surveys have found that 20% of medical students had selected their specialty of choice by the end of medical school and a further 16.7% by the end of their first postgraduate year (12, 13). If ICM is to attract the brightest and most promising of the graduates, these figures are a sober reminder that exposure needs to occur early in the young doctors’ career.
CONCLUSIONS The debate on whether ICM should be an independent medical specialty or alternatively a super/subspecialty of multiple other medical specialties generally has a focus on training programs. In the opinion of the author, the major driving force is a desire to have ICM seen and act independently, albeit in cooperation with other specialty consultants. This is an imperative if we as a profession are to manage the challenges that face us, in order to provide optimal care to our patients. More cohesive training programs by necessity follow this move to independence. Experiences in those domains that have already adopted single entry training programs demonstrate that many of the concerns raised by those opposing such a move do not eventuate. However, other concerns unfold, some unexpected, some not. Such concerns include attracting the most innovative doctors to ICM while not creating training programs that stifle initiative, nurturing future leaders of the profession, and balancing training capacity with workforce requirements. In an ever changing healthcare environment, future unknowns will inevitably accompany the evolution of ICM as a proud and progressive medical specialty, rising to future challenges of a society expecting first-class medical care. Challenges pertinent to ICM include fiscal responsibility in providing an expensive service, moral responsibility in determining who should receive complex therapy and who shouldn’t, identifying the boundaries of our practice both within and without the ICU, balancing the forces of evidence-based medicine with practical intuitive care, maintaining cooperative relationships with other groups within the hospital, and managing ever increasing and complex technology. Wisdom is required to manage the delicate balance between guidance and control.
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McLean 3. Trubuhovitch R, Judson J: Intensive Care in New Zealand—A History of the New Zealand Region of ANZICS. New Zealand, Department Critical Care Medicine, Auckland Hospital, 2001 4. Phillips G, Trubuhovitch R: A Record of Events: The First 25 Years 1975–2000. ANZICS, Department of Critical Care Medicine, Auckland Hospital, Auckland, 2001 5. Freebairn R: College of intensive care medicine in the antipodes. ICU Manage 2014; 14:42–44 6. College of Intensive Care Medicine: Training Program 2014. Available at: http://www.cicm.org.au/Trainees/Program/2014-Program. Accessed April 30, 2015 7. Bevan R, Freebairn R, Lee R: College of Intensive Care Medicine: Changes to intensive care medicine training. Crit Care Resusc 2014; 16:291–293 8. Rubulotta F, Moreno R, Rhodes A: Intensive care medicine: Finding its way in the “European labyrinth.” Intensive Care Med 2011; 37:1907–1912
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9. Van Aken H, Vallet B, Mellin-Olsen J: Comment on Rubulotta et al: Intensive care medicine: Finding its way in the “European labyrinth.” Intensive Care Med 2012; 38:1074–1075; author reply 1076 10. Venkatesh B, Freebairn R: Assessment of the distribution and professional roles of the new Fellows of the College of Intensive Care Medicine of Australia and New Zealand. Crit Care Resusc 2013; 15:327–328 11. Whereat SE, McLean AS: Survey of the current status of teaching intensive care medicine in Australia and New Zealand medical schools. Crit Care Med 2012; 40:430–434 12. Joyce CM, Stoelwinder JU, McNeil JJ, et al: Riding the wave: Current and emerging trends in graduates from Australian University Medical Schools. Med J Aust 2007; 186:309–312 13. Harris MG, Gavel PH, Young JR: Factors influencing the choice of specialty of Australian medical graduates. Med J Aust 2005; 183:295–300
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