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Intensive care medicine: a multidisciplinary approach!

2011; Lippincott Williams & Wilkins; Volume: 28; Issue: 5 Linguagem: Inglês

10.1097/eja.0b013e328345a441

1365-2346

Hugo Van Aken, Jannicke Mellin‐Olsen, Paolo Pelosi,

Respiratory Support and Mechanisms

Intensive care medicine (ICM) is unique in that it deals with the most severely ill patients in almost all fields of medicine. It is demanding in all aspects from a theoretical, practical, co-operational and personal perspective. It is also characterised by a rapid development in diagnostic and treatment options. Furthermore, the organisational and manpower characteristics of European healthcare have been changing over time. Hence, the official status of ICM warrants unbiased consideration. One option to improve the visibility and attractiveness of ICM might be to aim to install a new primary speciality of ICM in Europe. Such a development may lead to more competent doctors in the ICUs and improve the status of ICM within the healthcare system. Presently, the European Directive on recognition of professional qualifications (Directive 2005/36/EC of the European Parliament) does not identify ICM as a primary medical speciality.1 The European Union requires that, to become a primary speciality, it must be recognised in at least two fifths of the member states and, at the same time, by a particular majority (a weighted vote that is determined by the population of each country and other factors and giving what is called a 'qualified majority') in a committee on qualification of the European Commission (not only for medical professions but generally for all protected professions). In addition, to create a specialist section for ICM within the European Union of Medical Specialists (UEMS), ICM has to be recognised as an independent speciality by more than one third of the European Union member states and must be registered in the official journal of the European Commission (Medical Directives). Currently, ICM is an independent speciality only in Spain (member of the European Union) and in Switzerland (member of the European economic area). In 10 countries of the European Union (Table 1), ICM can be practised as a 'particular qualification' with a common training programme for specialists with board certification in a variety of base disciplines (anaesthesiology, cardiac surgery, cardiology, internal medicine, neurology, neurosurgery, paediatrics, respiratory medicine and surgery). A 'particular qualification' is an area of expertise in addition to a primary speciality qualification in which extra expertise outside the domain of the primary speciality is required to provide high-quality patient care.Table 1: Countries where intensive care medicine can be practisedIn the remaining 17 countries of the European Union and the remaining two countries of the economic area, ICM is part of the training programme of anaesthesiology (among others) with different lengths of training varying from 6 to 24 months. However, the training programme for anaesthesiology also ranges from 36 to 72 months in these countries. As the requirements for a primary speciality are not fulfilled for ICM, this would be a cumbersome way, but worth the effort if it is considered beneficial to acquire this status. A better way forward is to incorporate ICM as a 'particular qualification' in the revision of the European Directive 2005/36/EC in the year 2012. In a meeting of the Multidisciplinary Joint Committee of Intensive Care Medicine of the UEMS (MJCICM) in April 2008, the nine medical disciplines involved in ICM voted against the idea that ICM should become an independent primary speciality. On 19 April 2008, this proposal was supported by an overwhelming majority of the members of the Council of the UEMS. The reasons are rational and obvious. Most importantly, ICM is considered to be too complex to be covered by one medical speciality alone. Rather, the close co-operation of physicians treating the underlying disease and of physicians treating accompanying organ dysfunction and failure, and – if required – of specialists for extraordinary clinical problems, is necessary. A separation of ICM would tend to impede this mutual communication and collaboration among different professionals with specific knowledge, expertise and skills, rather than foster it. Thus, a multidisciplinary approach is necessary to facilitate the required high-level quality ICM for the critically ill patient. However, ICUs also need a clearly defined ICU leader to ensure a sound structure and delivery of a high level of care. The basic primary medical speciality of ICU leaders may differ.2 Another important aspect with respect to the organisational structure of ICUs is the question of whether outcomes of patients treated on specialised units are better than those of patients on general ICUs. It has often been suggested that ICUs with greater diagnostic diversity are associated with worse outcome. However, the opposite is true, as demonstrated recently in two larger studies.3,4 Current evidence indicates that patient outcomes are better when patients are cared for by trained intensivists.5 In Europe, this can be achieved by facilitating the acquisition of agreed common competencies in ICM by trainees from the various primary speciality training programmes involved in ICM. Furthermore, as ICM is extremely demanding physically and mentally, one would expect that severe problems will occur with physicians who will have to leave ICM after some years due to 'burnout'.6 Creating ICM as a primary speciality would disqualify them from working in another specialism, whereas the 'particular qualification' concept allows them to return to their 'mother disciplines' or to rotate back there for some time. ICM was the first discipline in Europe to develop a multidisciplinary training programme based on the acquisition of competencies: clearly defined sets of knowledge, skills, attitudes and behaviours which together define the basic abilities of an 'intensivist'. The Competency-Based Training in Intensive Care in Europe (CoBaTrICE) project and training programme (www.cobatrice.org), supported by a grant from the European Community's Leonardo Programme, undertook an international survey of training in adult ICM7 and, using consensus techniques, defined the core (minimum) competencies required of a specialist.8 In the survey of ICM training programmes in European Union Member States, the median duration of training is 24 months. The 102 competencies defined by the CoBaTrICE programme provide a sound basis for identifying ICM within the directive as a 'particular qualification'. The European Society of Anaesthesiology (ESA), the European Board of Anaesthesiology of the UEMS (EBA) and the Multidisciplinary Joint Committee of Intensive Care Medicine (UEMS MJCIM) do not support the proposal that ICM should become a primary specialty, as suggested in a recent article in The Lancet.9 Building new fences between areas of medicine is counterproductive with regard to the challenges of modern medicine. The aim should rather be that doctors with various relevant backgrounds and common formalised additional training work together to the benefit of each individual patient and the improvement of quality of ICM. This article was checked and accepted by the Editors, but was not sent for external peer-review.