Intensive Care Medicine: Are we losing ground?

En las páginas 8-10 de la ESA Newsletter aparece un interesante articulo de Jannicke Mellin -Olsen , President of the European Board of Anaesthesiology (EBA ) (Intensive Care Medicine: Are we losing ground?) sobre la medicina de cuidados intensivos en Europa y el interés de una especialidad primaria.



Intensive Care Medicine: Are we losing ground?

Anaesthesiologists pioneered the field of intensive care medicine (ICM) - to name just a few:

• Prof. John Severinghaus for his contribution to the interpretation of gas-exchange and acid base during anaesthesia and blood gas analysis;

• Prof. Bjørn Ibsen, the founding father of intensive care and hero of the 1952 Copenhagen polio epidemic;

• Prof. John Lundy, a pioneer in transfusion medicine, balanced anaesthesia and for the use of ventilators, oxygen tents and more;

• Prof. Peter Safar who is the father of cardiopulmonary resuscitation and recognised as the founder of critical care medicine in the USA.

But we our glorious past does not entitle us to be the ICM leaders in the future.

We need to continuously prove that we are worthy.

Anaesthesiology includes several areas of expertise, including:

• Anaesthesia in the operating theatre and in other locations;

• Post anaesthetic Care Units (PACU);

• Intensive care medicine - surgical, medical and specialised;

• Critical emergency medicine inside and outside the hospital;

• Pain treatment - acute, chronic and palliative care.

This means that Anaesthesiology is not only dedicated to perioperative medicine but also to the provision of acute care. Acute care identifies the necessary treatment of a disease for a short period of time in which a patient is generally treated for a brief, but severe episode of illness. In the future, the increasing need for acute care combined with financial restrictions, will stimulate re-structuring of hospitals to develop acute care facilities.

The goal will be to discharge the patient as soon as he or she is deemed sufficiently stable, with appropriate discharge instructions.

All these components combined, and not independently, are definitely important to make Anaesthesiology one of the most fascinating, ongoing developing and innovative areas in medicine in recent decades.

ICM as a separate speciality?

Will Intensive Care Medicine (ICM) leave Anaesthesiology and become a separate speciality?

The experience from Spain, the only European Union (EU) country where it is recognised as such, is that it does not appear to be as good a solution as intended (in addition, ICM is a separate speciality in Switzerland).

The major strength of the current approach in most countries is the multidisciplinary approach. The entry point could be anaesthesiology, cardiology, neurosurgery, paediatrics, etc. ICM could also be a sub-speciality, particularly of Anaesthesiology. In several countries, there is more than one model.

In 2007, Prof. Julian Bion, the European Society of Intensive Care Medicine (ESICM. president, proposed the introduction of ICM as a separate speciality at the European level.

The requirement for a separate speciality is that the discipline must be recognised in at least 2/5th of the Member States and supported by a weighted ‘qualified’ majority (determined by the population of each country and other factors) by the committee on Qualifications of the European Commission.

At the same time Prof. Hugo Van Aken, Chair of the UEMS Multidisciplinary Joint Committee of Intensive Care Medicine of the UEMS, negotiated with Prof. Bion on an alternative approach: The particular competence of intensive care medicine. This approach was unanimously agreed by the nine UEMS sections (anaesthesiology, cardiac surgery, cardiology, internal medicine, neurology, neurosurgery, paediatrics, pneumonology and surgery). The reasons are obvious: A reduced involvement of the primary specialties in intensive care medicine and enormous problems with physicians who will leave intensive care medicine after a couple of years due to the enormous physical and mental stress (burnout). In April 2010 the proposal to incorporate intensive care medicine into the medical directive 2005/36/EC was discussed again with the Internal Market and Services Directorate General of the EU.

This meeting was initiated by Prof. Van Aken, in his capacity as president of the Multidisciplinary Joint Committee on Intensive Care Medicine of the UEMS, to request the inclusion of the concept of particular competence within the Directive on the recognition of professional qualifications (2005/36/ EC). In most European countries, intensive care medicine can be obtained as a “particular competence” with a common training programme for specialists with Board certification in a variety of base disciplines.



Symposium in Belgrade: “Who are supposed to be intensivists”

The recent Serbian congress which included the first Balkan Symposium of Anaesthesiologists and Intensivists, in Belgrade in October 2010, put the question on the agenda by arranging WFSA (World Federation of Societies of Anaesthesiologists) session on “Who are supposed to be intensivists?”

The panel consisted of:

• Prof. Dragan Vučković, Serbia, the Congress President

• Prof. Philippe Scherpereel, France, Chairman of the WFSA Scientific Committee

• Prof. Hugo Van Aken, Germany, Chairman of the UEMS Multidisciplinary Joint Commitment of Intensive Care Medicine and Chairman of the NASC Committee

• Prof. Paolo Pelosi, Italy, President ESA

• Prof. Gabriel Gurman, Israel, Founder and Faculty Chairman, ISIA

• Dr. Jannicke Mellin-Olsen, President of the EBA and Chairman of the WFSA Education Committee



ICM as separate speciality – pros and cons The arguments that have been launched in favour of a separate ICM speciality are:

• It would acknowledge quality training and practice in ICM

• Self-regulation and responsibility for professional standards may translate into even better (more reliable) patient care

• It would make ICM a more attractive career option for committed trainees

• The profile of ICM in universities would be raised: »» It would be easier to attract the next generation of intensivists; »» It would contribute to teaching in acute care; »» There would be better access to research funding.

• Consistent with European Commission’s intentions: »» Focus training on competencies; »» Harmonise standards; »» Free movement of professionals.



But there are other arguments against:

• It would lead to reduced involvement of primary specialities in ICM, and thus, impair patient care. One of the strengths of current ICM is its multidisciplinary nature.

• It could potentially create professional barriers within the patient journey.

• Workforce issues: »» here is no doubt that ICM is hard on mental level – the intensivists are with the sickest of the sick all the time, with relatives in mental shock, and the risk of burn-out is high. If ICM becomes a primary speciality, then there will be no escape to other fields within one’s speciality. Furthermore, there is no guarantee that ICM will become a popular career choice. From where are we going to recruit all these new specialists? »» For Anaesthesiology, we must also think about the attractiveness of our speciality. Currently, there is a worldwide shortage of anaesthesiologists.

ICM gives us an opportunity to take continuous care of the patients over a longer period of time, and it gives us more challenges and may be more rewarding than being gasmen and women only.

»» If we are to stay in the operating theatre all the time, for the rest of our lives, many of us would get bored. Then it certainly will affect the recruitment to and sustainability of our speciality. A trend for those countries where Anaesthesiology is a popular speciality is notably that all four pillars are a part of our training.

• Anaesthesiology is applied physiology.

It contains pain and sedation, fluid and electrolyte and blood product treatments; we administer antibiotics and cardio active medications. We are used to emergencies and acute situations, we are skilful in invasive procedures, used to taking quick decisions and multispecialty teamwork is our order of the day. Prof.Gurman provocatively argued that anaesthesia is ICM + nitrous oxide!

What gives the best patient care?

The panel did agree that intensive care patients, whatever their level of risk, are best treated where more high-risk patients are treated. It has been demonstrated that the “optimal” number of individual ICU beds in a department is 8 – 12. There should be full time, on site specialists in the ICU . Special expert consultations, like microbiologists and infectious disease specialists, are useful. We know that standardised, optimised procedures and protocols can be defined and better fulfilled by a closed team.

Complications of invasive monitoring can be reduced by a dedicated ICU team.

Uniform admission and discharge policies should be installed.

ICM as a particular professional qualification

The panel was uniform in the conclusion that we must work hard to ensure that intensive care medicine remains an integral part of our speciality. This does not mean that ICM is exclusively for anaesthesiologists.

The panel would rather recommend that ICM is incorporated in the Directive 2005/36/EV of the European Parliament and of the Council on the recognition of professional qualifications as a particular medical competence/ qualification in Europe.

The definition of a particular medical qualification is: “An area of expertise in addition to a primary specialty, where extra expertise outside the domain of the specific speciality is required to provide high quality patient care by multidisciplinary input from doctors from various specialities with extra, relevant expertise.”

This means that one could enter the field from many various specialties, and acquire a specified list of competencies. These have been described by the CoBaTrICE programme (www.cobatrice.org.The CoBaTrice reckons that those competencies can be achieved during two years. Of those five years that the European Board has recommended for speciality training, one year is supposed to take place in intensive care medicine. This means that for us, one additional year will be required.

Positioning for the future –

the Scandinavian approach We need to define our own future. The Scandinavian Society tried to do just that when they organised a web based survey for their members –to explore what the members wanted and to make everyone accountable for the strategy for the future. Based on this, a strategic position paper for the future was developed. For ICM, it was stated: “Further training in intensive care medicine of specialists in Anaesthesiology will increase the quality of treatment and patient outcomes and ensure that anaesthesiologists remain in the lead of this medical field in Scandinavia.

A set of minimum requirements for other specialities to enter advanced educational programmes in intensive care needs to be defined as multidisciplinary intensive care develops further as a PMC. The SSAI suggests that 24 months of training in perioperative anaesthesia care required for other UEMSrecognised medical specialists to be eligible to enter an educational programme leading to a PMC in intensive care medicine.”

This undertaking makes it easier for the Scandinavian Society to define their position. Similar efforts can easily be done in other societies in Europe. The EBA will then use this input in its political activities in the EU, both as a single entity and through our co-operation and leadership (Prof. Van Aken) in the Multidisciplinary Joint Committee of Intensive Care Medicine within the UEMS.

At this time, we support the proposal that:

• We do not support ICM as a separate speciality.

• The UEMS recommends the incorporation of Intensive Care Medicine in Directive 2005/36/EC of the European Parliament & Council on the recognition of professional qualifications, as a particular medical competence/qualification.

• The content of training be defined and managed through the CoBaTrICE collaboration and monitored via the EBICM (European Board of Intensive Care Medicine.

• The current EDA (European Diploma of Anaesthesiology and Intensive Care Medicine) examination is an examination also for ICM, and this should be marketed and recognised.

• Anaesthesiologists should be at the lead, not because we have the expertise on how to intubate and insert catheters, etc., but because we, if we follow the recommendations, will prove ourselves to be the most competent.



Bibliografia:

I Iapichino G et al. Volume of activity and occupancy rate in intensive care units. Association with mortality. Intensive Care Med 2004; 30:290–297

II Burchardi H, Moerer O. Twenty-four hour presence of physicians in the ICU. Crit Care 2001; 5:131-137.

III Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest 2009;135:1038–1044

IV Kim MM et al. The effect of multidisciplinary care teams on intensive care unit mortality Arch Intern Med 2010;170:369-376

V Aneman A, Mellin-Olsen J, Søreide E. The future role of the Scandinavian anaesthesiologist: a web-based survey. Acta Anaesthesiol Scand. 2010; 54:1071-1076.

VI Søreide E et al. Shaping the future of Scandinavian anaesthesiology: a position paper by the SSAI. Acta Anaesthesiol Scand. 2010; 54:1062-1070.