Editorials
REFERENCES 1. Mehlhorn J, Freytag A, Schmidt K, et al: Rehabilitation Interventions for Postintensive Care Syndrome: A Systematic Review. Crit Care Med 2014; 42:1263-1271 2. Davydow DS, Gifford JM, Desai SV, et al: Posttraumatic stress disorder following intensive care: A systematic review. Gen Hosp Psychiatry 2008; 30:421-434 3. Davydow DS, Gifford JM, Desai SV, et al: Depression in general intensive care unit survivors: A systematio review. Intensive Care Med 2009; 35:796-809 4. Wilcox ME, Brummel NE, Archer K, et al: Cognitive dysfunction in ICU patients: Risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41 ;S81-S98 5. Stevens RD, Dowdy DW, Michaels RK, et al: Neuromuscular dysfunction acquired in critical illness: A systematic review. Intensive Care Med 2007; 33:1 876-1891 6. Needham DM, Davidson J, Cohen H, et al: Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Crit Care Med 201 2; 40:502-509 7. Schweickert WD, Pohlman MC, Pohlman AS, et al: Early physical and occupational therapy in meohanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009; 373:1 874-1882 8. Peris A, Bonizzoli M, lozzelli D, et al: Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress
9.
10.
11.
12.
13.
14. 15.
disorders, anxiety and depression symptoms in critically ill patients. C/-/Í Care 2011 ; 15:R41 Schelling G, Roozendaal B, KrauseneokT, et al: Efficacy of hydrocortisone in preventing posttraumatic stress disorder following critical illness and major surgery. Ann N Y Acad Sei 2006; 1071:46-53 Jones C, Bäckman C, Capuzzo M, et al; RACHEL group: Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: A randomised, controlled trial. Crit Care 2010; 14:R168 Garrouste-Crgeas M, Coquet I, Périer A, et al: Impact of an intensive care unit diary on psychological distress in patients and relatives. Crit Care Med 201 2; 40:2033-2040 Bienvenu OJ, Gould NF, Mason ST, et al: Anxiety disorders prevention: Overview and focus on post-traumatic stress disorder. Minerva Psichiatr 2009; 50:265-275 McKinley S, Aitken LM, Alison JA, et al: Sleep and other factors associated with mental health and psychological distress after intensive care for critical illness. Intensive Care Med 201 2; 38:627-633 Parker A, Tehranchi KM, Needham DM: Critical care rehabilitation trials: The importance of 'usual care'. Crit Care 2013; 17;R183 Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al: Depressive symptoms and impaired physical function after acute lung injury: A 2-year longitudinal study. Am J Respir Crit Care Med 2012; 185:517-524
Training Requirements for Critical Care Medicine Internal Medicine-Based Programs: Helpful, Haphazard, or Harmony?* Pamela A. Lipsett, MD, MHPE, FCCM, FACS Department of Surgery; and Department of Anesthesiology and Critical Care Medicine Johns Hopkins University Schools of Medicine and Nursing Baltimore, MD
L
eaders in critical care medicine (CCM) have been increasingly concerned about the availabihty of providers for our critically ill and injured patients witb the projected need far exceeding the available providers (1). The subject of critical care training has been the focus of 23 publications since 2010, several of wbicb bave pointed out the need for additional trainees, the differences in training requirements between or among specialties, and the potential for burnout within the specialty (2-6, 8). Although each of these publications has been well written and appreciated among the critical 'See also p. 1272. Key Words: critical care fellowship; medical education; resident; training The author has disclosed that she does not have any potential conflicts of interest. Copyright ® 2014 by the Society of Critioal Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.000000000000035
Critical Care Medicine
care community, few changes in training requirements have been implemented to date. In order to gain consensus, the Critical Care Society Collaborative (CCSC) and its corresponding parent organizations have considered and made recommendations regarding the apparent inconsistencies in the CCM pathways that originate in internal medicine (IM)-based programs (9). These issues have previously been brought forward to the IM-Residency Review Committee (IM-RRC) in a letter sponsored by the CCSC requesting reconsideration of the number of fellowship requirements at the principal site, the requirement for supervising faculty to be from IM, and the number of bronchoscopies required of IM-CCM 2-year trainees (M. Levy, personal communication, 2009). Although the letter had been received, no action was ever taken. In this issue of Critical Care Medicine, the CCSC (9) publishes their consensus opinion regarding the differences in training requirements between the approved certification pathways for CCM in IM. On a positive note, the IM-RRC recognizes that individuals who desire to practice as intensivists may choose to train in Pulmonary, another IM subspecialty, or from training in advanced IM. While recognizing that the entry point may vary, and thus individual competency and experience may vary, separate (and different) institutional requirements have been imposed on training programs in IMbased programs. Furthermore, some of these requirements www.ccmjournal.org
1321
Editorials
also differ from those in other CCM-based training programs in Anesthesiology and Surgery. One of the primary concerns of the authors is the requirement for three of five IM fellowships at the primary site in 2-year IM-CCM programs versus two of four in Pulmonary CCM-based programs. While there is a numerical difference in two versus three programs, it seems internally consistent that if a pulmonary program is present, there is already "credit" for a fellowship program. The CCSC has considered this requirement overly burdensome (9), and neither Anesthesiology CCM nor Surgical Critical Care has this organizational requirement. Both the authors and I were unable to find any published data to support this requirement and one can only postulate the reasons for this requirement. Does the RRC-IM have data to suggest that patient population is different in institutions where additional fellowships are not present? Are fellows supported in some more positive manner if there are more of them in different specialties? At the very least, the RRC-IM should make it clear as to why this requirement persists. The authors also consider the requirement of key clinical faculty ratios and whether non-IM-based providers can serve as faculty or supervisors. Anesthesiology CCM and Surgery programs do not use the term "key clinical faculty" but allow non-Anesthesiology CCM or Surgery faculty to supervise trainees from an alternative specialty. Surgery programs require a 1:1 ratio of surgery faculty to trainees (in addition to the Program Director), whereas Anesthesiology CCM requires a 1:2 ratio. So are the IM-CCM and Pulmonary CCM requirements in harmony with other specialties and are they consistent with each other? The IM-CCM requirements fall in between the Anesthesiology CCM and Surgery requirements. If the numher of fellows is less than or equal to three, then the requirement is similar to Anesthesiology CCM and if it is greater than three, it is similar to Surgery. The requirement does not, however, seem to be superficially internally consistent, perhaps due to the larger size of the Pulmonary CCM programs and the need for a greater number of faculty at small programs (5 -I- Program director) and a fewer number (1:1.5) only when there are a large number of fellows. If Pulmonary CCM programs had only six or fewer fellows, they would he required to have six faculties, a 1:1 ratio. The availabihty of faculty to both mentor and supervise fellows is an essential element in their professional development. While one could argue whether that ratio should be 1:1,1:1.5, or 1:2, clearly faculty needs to be available to trainees. In the updated requirements, key faculty members are confined to American Board of Internal Medicine certification, but there is a clear expectation that specialists from IM and other non-IM faculty should be involved in training fellows. As medical training moves into milestones and competency-based training, the use of a minimum number of procedures as a proxy for competency is likely to decrease (10, 11). The requirement of 50 bronchoscopy procedures in IM-CCM programs does not seem to be based on published data about competency. While it may be reasonable to collect data about 1322
www.ccmjournal.org
experience, a skiU-based competency assessment should replace a minimum of case numbers. Finally, the IM-RRC has placed a limit on the proportion of emergency medicine trainees in the IM-CCM-based programs. The rationale for choosing 25% has not been articulated and most likely represents a political rather than a professional development or competency stance. Are the requirements of the RRC-IM haphazard, helpful, or can they be harmonized within IM and/or across specialties? While it is laudahle to have multiple pathways into critical care, they should offer equivalent training and should not add administrative burden to programs. The RRC-IM should address their reasoning for a specific number of fellowships at the primary site, and if sufficient evidence is not availahle to support their requirement, it should he reconsidered. Furthermore, the requirement for any number of bronchoscopies should be replaced with a competency-based milestone. The faculty to resident ratio within IM should be uniform, although allowances should be made for the size of the program so that minimum standards are met whether the program has a large number of residents or a smaller number of residents. Finally, the IM-RRC should consider whether key faculty can be from IM only, when the majority of units are mixed medical surgical units and may have qualified CCM specialists who would teach a perspective that may be unique to their discipline creating an opportunity for greater, not lesser, learning among the fellows. In the end, the entry pathways into CCM should allow many trihutaries, but the harmony should come in the end product of a competency-based training model that allows trainees from any discipline, let alone the same discipline to care for critically ill and injured patients. We should remove administrative burdens that are based on tradition, discipline, or protection of specialty development.
REFERENCES 1. Halpern NA, Pastores SM, Oropeilo JM, et al: Critioal oare medioine in the United States: Addressing the intensivist shortage and image of the speoialty. Crit Care Med 2013; 41:2754-2761 2. Gupta R, Zad O, Jimenez E: Analysis of the variations between Aooreditation Council for Graduate Medioal Eduoation requirements for oritioal oare training programs and their effeots on the ourrent oritioal oare workforoe. J Crit Care 2013; 28:1042-1047 3. Diringer E, Yende S: Protoool-direoted oare in the ICU: Making a future generation of intensivists less knowledgeable? Crit Care 201 2; 16:307 4. Diaz-Guzman E, Colbert CY, Mannino DM, et al: 24/7 in-house intensivist ooverage and fellowship eduoation: A oross-seotional survey of aoademio medioal oenters in the United States. Chest 2012; 141:959-966 5. Pastores SM, O'Connor MF, Kleinpell RM, et al: The Aooreditation Counoil for Graduate Medioal Eduoation resident duty hour new standards: History, changes, and impaot on staffing of intensive oare units. Crit Care Med 2011 ; 39:2540-2549 6. Musaoohio MJ Jr, Smith AP, MoNeal CA, et al: Neuro-oritioal oare skills training using a human patient simulator. Neurocrit Care 2010; 13:169-175 7 Safar P, Dekornfeld TJ, Pearson JW, et al: The intensive oare unit: A three year experience at Baltimore oity hospitals. Anaesthesia 1961 ; 16:275-284 May 2014 • Volume 42 • Number 5
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
REFERENCES 1. Mehlhorn J, Freytag A, Schmidt K, et al: Rehabilitation Interventions for Postintensive Care Syndrome: A Systematic Review. Crit Care Med 2014; 42:1263-1271 2. Davydow DS, Gifford JM, Desai SV, et al: Posttraumatic stress disorder following intensive care: A systematic review. Gen Hosp Psychiatry 2008; 30:421-434 3. Davydow DS, Gifford JM, Desai SV, et al: Depression in general intensive care unit survivors: A systematio review. Intensive Care Med 2009; 35:796-809 4. Wilcox ME, Brummel NE, Archer K, et al: Cognitive dysfunction in ICU patients: Risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41 ;S81-S98 5. Stevens RD, Dowdy DW, Michaels RK, et al: Neuromuscular dysfunction acquired in critical illness: A systematic review. Intensive Care Med 2007; 33:1 876-1891 6. Needham DM, Davidson J, Cohen H, et al: Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Crit Care Med 201 2; 40:502-509 7. Schweickert WD, Pohlman MC, Pohlman AS, et al: Early physical and occupational therapy in meohanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009; 373:1 874-1882 8. Peris A, Bonizzoli M, lozzelli D, et al: Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress
9.
10.
11.
12.
13.
14. 15.
disorders, anxiety and depression symptoms in critically ill patients. C/-/Í Care 2011 ; 15:R41 Schelling G, Roozendaal B, KrauseneokT, et al: Efficacy of hydrocortisone in preventing posttraumatic stress disorder following critical illness and major surgery. Ann N Y Acad Sei 2006; 1071:46-53 Jones C, Bäckman C, Capuzzo M, et al; RACHEL group: Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: A randomised, controlled trial. Crit Care 2010; 14:R168 Garrouste-Crgeas M, Coquet I, Périer A, et al: Impact of an intensive care unit diary on psychological distress in patients and relatives. Crit Care Med 201 2; 40:2033-2040 Bienvenu OJ, Gould NF, Mason ST, et al: Anxiety disorders prevention: Overview and focus on post-traumatic stress disorder. Minerva Psichiatr 2009; 50:265-275 McKinley S, Aitken LM, Alison JA, et al: Sleep and other factors associated with mental health and psychological distress after intensive care for critical illness. Intensive Care Med 201 2; 38:627-633 Parker A, Tehranchi KM, Needham DM: Critical care rehabilitation trials: The importance of 'usual care'. Crit Care 2013; 17;R183 Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al: Depressive symptoms and impaired physical function after acute lung injury: A 2-year longitudinal study. Am J Respir Crit Care Med 2012; 185:517-524
Training Requirements for Critical Care Medicine Internal Medicine-Based Programs: Helpful, Haphazard, or Harmony?* Pamela A. Lipsett, MD, MHPE, FCCM, FACS Department of Surgery; and Department of Anesthesiology and Critical Care Medicine Johns Hopkins University Schools of Medicine and Nursing Baltimore, MD
L
eaders in critical care medicine (CCM) have been increasingly concerned about the availabihty of providers for our critically ill and injured patients witb the projected need far exceeding the available providers (1). The subject of critical care training has been the focus of 23 publications since 2010, several of wbicb bave pointed out the need for additional trainees, the differences in training requirements between or among specialties, and the potential for burnout within the specialty (2-6, 8). Although each of these publications has been well written and appreciated among the critical 'See also p. 1272. Key Words: critical care fellowship; medical education; resident; training The author has disclosed that she does not have any potential conflicts of interest. Copyright ® 2014 by the Society of Critioal Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.000000000000035
Critical Care Medicine
care community, few changes in training requirements have been implemented to date. In order to gain consensus, the Critical Care Society Collaborative (CCSC) and its corresponding parent organizations have considered and made recommendations regarding the apparent inconsistencies in the CCM pathways that originate in internal medicine (IM)-based programs (9). These issues have previously been brought forward to the IM-Residency Review Committee (IM-RRC) in a letter sponsored by the CCSC requesting reconsideration of the number of fellowship requirements at the principal site, the requirement for supervising faculty to be from IM, and the number of bronchoscopies required of IM-CCM 2-year trainees (M. Levy, personal communication, 2009). Although the letter had been received, no action was ever taken. In this issue of Critical Care Medicine, the CCSC (9) publishes their consensus opinion regarding the differences in training requirements between the approved certification pathways for CCM in IM. On a positive note, the IM-RRC recognizes that individuals who desire to practice as intensivists may choose to train in Pulmonary, another IM subspecialty, or from training in advanced IM. While recognizing that the entry point may vary, and thus individual competency and experience may vary, separate (and different) institutional requirements have been imposed on training programs in IMbased programs. Furthermore, some of these requirements www.ccmjournal.org
1321
Editorials
also differ from those in other CCM-based training programs in Anesthesiology and Surgery. One of the primary concerns of the authors is the requirement for three of five IM fellowships at the primary site in 2-year IM-CCM programs versus two of four in Pulmonary CCM-based programs. While there is a numerical difference in two versus three programs, it seems internally consistent that if a pulmonary program is present, there is already "credit" for a fellowship program. The CCSC has considered this requirement overly burdensome (9), and neither Anesthesiology CCM nor Surgical Critical Care has this organizational requirement. Both the authors and I were unable to find any published data to support this requirement and one can only postulate the reasons for this requirement. Does the RRC-IM have data to suggest that patient population is different in institutions where additional fellowships are not present? Are fellows supported in some more positive manner if there are more of them in different specialties? At the very least, the RRC-IM should make it clear as to why this requirement persists. The authors also consider the requirement of key clinical faculty ratios and whether non-IM-based providers can serve as faculty or supervisors. Anesthesiology CCM and Surgery programs do not use the term "key clinical faculty" but allow non-Anesthesiology CCM or Surgery faculty to supervise trainees from an alternative specialty. Surgery programs require a 1:1 ratio of surgery faculty to trainees (in addition to the Program Director), whereas Anesthesiology CCM requires a 1:2 ratio. So are the IM-CCM and Pulmonary CCM requirements in harmony with other specialties and are they consistent with each other? The IM-CCM requirements fall in between the Anesthesiology CCM and Surgery requirements. If the numher of fellows is less than or equal to three, then the requirement is similar to Anesthesiology CCM and if it is greater than three, it is similar to Surgery. The requirement does not, however, seem to be superficially internally consistent, perhaps due to the larger size of the Pulmonary CCM programs and the need for a greater number of faculty at small programs (5 -I- Program director) and a fewer number (1:1.5) only when there are a large number of fellows. If Pulmonary CCM programs had only six or fewer fellows, they would he required to have six faculties, a 1:1 ratio. The availabihty of faculty to both mentor and supervise fellows is an essential element in their professional development. While one could argue whether that ratio should be 1:1,1:1.5, or 1:2, clearly faculty needs to be available to trainees. In the updated requirements, key faculty members are confined to American Board of Internal Medicine certification, but there is a clear expectation that specialists from IM and other non-IM faculty should be involved in training fellows. As medical training moves into milestones and competency-based training, the use of a minimum number of procedures as a proxy for competency is likely to decrease (10, 11). The requirement of 50 bronchoscopy procedures in IM-CCM programs does not seem to be based on published data about competency. While it may be reasonable to collect data about 1322
www.ccmjournal.org
experience, a skiU-based competency assessment should replace a minimum of case numbers. Finally, the IM-RRC has placed a limit on the proportion of emergency medicine trainees in the IM-CCM-based programs. The rationale for choosing 25% has not been articulated and most likely represents a political rather than a professional development or competency stance. Are the requirements of the RRC-IM haphazard, helpful, or can they be harmonized within IM and/or across specialties? While it is laudahle to have multiple pathways into critical care, they should offer equivalent training and should not add administrative burden to programs. The RRC-IM should address their reasoning for a specific number of fellowships at the primary site, and if sufficient evidence is not availahle to support their requirement, it should he reconsidered. Furthermore, the requirement for any number of bronchoscopies should be replaced with a competency-based milestone. The faculty to resident ratio within IM should be uniform, although allowances should be made for the size of the program so that minimum standards are met whether the program has a large number of residents or a smaller number of residents. Finally, the IM-RRC should consider whether key faculty can be from IM only, when the majority of units are mixed medical surgical units and may have qualified CCM specialists who would teach a perspective that may be unique to their discipline creating an opportunity for greater, not lesser, learning among the fellows. In the end, the entry pathways into CCM should allow many trihutaries, but the harmony should come in the end product of a competency-based training model that allows trainees from any discipline, let alone the same discipline to care for critically ill and injured patients. We should remove administrative burdens that are based on tradition, discipline, or protection of specialty development.
REFERENCES 1. Halpern NA, Pastores SM, Oropeilo JM, et al: Critioal oare medioine in the United States: Addressing the intensivist shortage and image of the speoialty. Crit Care Med 2013; 41:2754-2761 2. Gupta R, Zad O, Jimenez E: Analysis of the variations between Aooreditation Council for Graduate Medioal Eduoation requirements for oritioal oare training programs and their effeots on the ourrent oritioal oare workforoe. J Crit Care 2013; 28:1042-1047 3. Diringer E, Yende S: Protoool-direoted oare in the ICU: Making a future generation of intensivists less knowledgeable? Crit Care 201 2; 16:307 4. Diaz-Guzman E, Colbert CY, Mannino DM, et al: 24/7 in-house intensivist ooverage and fellowship eduoation: A oross-seotional survey of aoademio medioal oenters in the United States. Chest 2012; 141:959-966 5. Pastores SM, O'Connor MF, Kleinpell RM, et al: The Aooreditation Counoil for Graduate Medioal Eduoation resident duty hour new standards: History, changes, and impaot on staffing of intensive oare units. Crit Care Med 2011 ; 39:2540-2549 6. Musaoohio MJ Jr, Smith AP, MoNeal CA, et al: Neuro-oritioal oare skills training using a human patient simulator. Neurocrit Care 2010; 13:169-175 7 Safar P, Dekornfeld TJ, Pearson JW, et al: The intensive oare unit: A three year experience at Baltimore oity hospitals. Anaesthesia 1961 ; 16:275-284 May 2014 • Volume 42 • Number 5
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
