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.