lunes, 23 de enero de 2012

Response to Rubulotta Special Article

Pamplona, December 9th, 2011

Dear colleague:

The special article by Rubulotta F, Moreno R and Rhodes A, published in the December issue of the official journal of the ESICM (ref. Intensive Care Med 2011; 37:1907-12) contains some inaccuracies about the development and future of Intensive Care Medicine (ICM) in Europe that should be clarified.

ICM is actually already recognised as a speciality in Europe, not as a primary or mother speciality but as a multidisciplinary one (ref. Intensive Care Med 2002; 28: 1505-11). Several different specialists acquire advanced competencies within or beyond their primary speciality to become intensivists (ref. Eur J Anaesthesiol 2011; 28: 313-5). This variability has never been shown to produce any negative impact in the outcome. The aim of the Competency Based Training in Intensive Care Medicine collaboration (CoBaTrICE) is to optimise the care of the critically ill patient through the development of common standards of training, independently of the primary speciality.

The Multidisciplinary Joint Committee for Intensive Care Medicine (MJCICM) was not created with the aim of facilitating the recognition of ICM as a speciality, but “to harmonise training programmes and achieve minimum standards of training and expertise among the member European Union states” (ref. Intensive Care Med 2002; 28: 1505-11). The reason for harmonisation should be to guarantee quality, safety and effectiveness of care and furthermore to facilitate free movement of specialists among European countries. That goal is not achieved by equipping Europe with a primary speciality but by harmonising competencies acquisition, through the CoBaTrICE programme, and by an evaluation at the end of training, through a formal examination. The MJCICM has always clearly pleaded for multidisciplinary access to ICM and does not support that ICM become a primary speciality (ref. Eur J Anaesthesiol 2011; 28: 313-5).

A primary speciality, present in Spain and in Switzerland, is neither necessary nor desirable. We can not ignore its negative consequences in Spain (cfr. Eur J Anaesthesiol 2011; 28: Jul 13. doi: 10.1097/EJA.0b013e3283499e27), the country with the longest experience with primary intensivists, with an impoverishment of anaesthesiology and other specialities dealing with critically ill patients. It is significant that Rubulotta’s paper ignores the presence of anaesthesia intensivists in Spain in charge of more than 40% of ICU beds in teaching hospitals (cfr. Intensive Care Med 2010; 36: 171).

The situation in Switzerland is also misunderstood. ICM as a speciality exists since 2001 but close to 100% of all physicians choose a dual specialization with five years in a basic speciality plus 2 years in ICM since this provides more professional opportunities. In the Swiss Society of ICM roughly 50% are specialists in Anaesthesiology/ICM, 40% in Internal Medicine/ICM, 10% in Paediatrics/ICM and very few in Surgery/ICM.

Related to free movement of physicians, an Italian anaesthesiologist fully trained in ICM in Italy who wants to move to the UK to work, faces the same problems as any other specialist in an advanced field of expertise. If one wants to work in pain medicine or in neonatal anaesthesia or as a liver transplant surgeon, one should prove one’s training and competence in that field. Recognition of a focused practice does not require the creation of a new primary speciality.

The road map for the recognition of ICM as a particular competence is the most appropriate way to facilitate the free movement of ICM specialists.

The ESICM can not defend a primary speciality without rejecting a multidisciplinary access to ICM, in conflict with the variety of national organisations involved in ICM in Europe. There is no monster to kill in the “European labyrinth”, as stated in the Rubulotta’s paper, but a need to foster the harmonisation of competencies and their evaluation.

The editors of “Intensive Care Medicine”, Prof. Mancebo and Antonelli, think that this letter is not really interesting to the vast majority of their readers. The opinion of Dr. Rubulotta was the opposite. The editors will not allow a dialogue about this issue that seems to be considered the official doctrine of the ESICM, against UEMS recommendations, but Dr. Rubulotta response encouraged me to spread this letter.

I would appreciate your wide spreading of this letter.

Thank you

Pablo Monedero

Vice-president of the National Committee of Anaesthesiology and Reanimation. Spanish Ministry of Health.

Secretary of the Intensive Care Section of the Spanish Society of Anaesthesiology and Reanimation.

ICU director. Clinica Universidad de Navarra.

1 comentario:

  1. Dear Dr Monedero,
    I am really happy that these issues are discussed because I feel there are still lots of differences and inaccuracies in the common knowledge of these matters. I believe this discussion will benefit young colleagues who do not know and experience European barriers until they do not try to work outside their own country. The European Directive (ED) 2005/36 entitled ‘the recognition of professional qualifications’ has been created for the free movement of specialists in Europe. This ED has nothing to do with the recognition of Intensive Care Medicine as a supra-specialty or a multidisciplinary specialty per se. The aim of this law is that all specialties listed in the document have easier and free movement across Europe. Intensive Care Medicine (because of the substantial differences among European Countries) has not been listed as a key specialty. This is not important in Spain or in the UK. This is a problem if young physicians want to use their own qualification in ICM to access another European countries. The CoBaTrICE competencies have been used in the attempt of identifying Intensive Care Medicine as a special Competence. Once again, the goal is not the development of the discipline in a specific country but the possibility of easier equivalence of ICM in European countries.
    The problem is that Spanish doctors have had several problems to work outside Spain regardless the quality of their training. This is a paradox created by current European regulations. The manuscript is not making a comparison on the quality of the training or the characteristic of the training in a single country but it is highlighting the barriers among European Nations. In 2012 the roadmap and the case for Intensive Care Medicine will be reconsidered. I am concerned that Intensive Care Medicine will not progress neither to become a mother speciality nor a special competence due to several differences and discrepancies among countries.

    I think this will not impact the training in Intensive Care Medicine in a single country but once again will keep all barriers. I do not believe that Brussels can remove these walls in the near future, so probably it is our duty at a National level to facilitate the free movement using easy measures such as a formal National accreditation or a diploma -or alternatively the use of EDIC-. I really believe this topic is interesting.