Comment on Rubulotta et al.: Intensive care medicine: finding its way in the “European labyrinth”

Correspondence


Comment on Rubulotta et al.: Intensive care medicine: finding its way in the “European labyrinth”

Hugo Van Aken1, Benoît Vallet2 and Jannicke Mellin-Olsen3, 4


We read with interest the Special Article by Rubulotta et al. [1] on the development and future of intensive care medicine (ICM) in Europe. In our view, some of the statements made in the article need clarification.

Although we agree that there is wide variability in the duration, quality, and consistency of training, which impedes free movement of specialists between European countries, this has never been shown to have a negative impact on the outcome, quality, or effectiveness of care. The Multidisciplinary Joint Committee in Intensive Care Medicine (MJCICM) was created ‘to harmonise training programmes and achieve minimum standards of training and expertise among the member European Union states’ [2]. It was not created with the aim of facilitating the recognition of ICM as a primary speciality. An important reason why harmonisation is desirable is to ensure the quality, safety, and effectiveness of care. In addition, it should facilitate the free movement of specialists among European countries.

This goal can be achieved by harmonising the acquisition of competencies through the Competency-Based Training in Intensive Care Education (CoBaTrICE) programme, and by evaluation at the end of training the competences through a formal examination. The aim of the CoBaTrICE is to optimise care for the critically ill patient by developing common standards of training, independently of the primary speciality.

The MJCICM therefore unanimously decided to request that the European authorities should incorporate ICM as a ‘particular qualification’ in the revision of European Directive 2005/36/EC in 2012. 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.

The MJCICM has always clearly pleaded for multidisciplinary access to ICM and does not support the idea of ICM becoming a primary speciality. Instead, ICM should be as a particular qualification open to all specialities involved in ICM, as it is already the case in many European countries [3]. Primary speciality status for the discipline, which currently exists in Spain and the UK (UK), is neither necessary nor desirable. In the UK, however, a dual pathway is possible; this means that a qualification in ICM can be obtained either as a primary speciality or as a particular qualification on top of another primary speciality (e.g., anaesthesiology, surgery, or internal medicine).

The reasons for this are clear and obvious: firstly, ICM appears to be too complex to be covered by a single medical speciality alone; secondly, separating ICM as a primary speciality would tend to impede mutual communication and collaboration among different professionals with specific knowledge, expertise, and skills; and thirdly, ICM is extremely demanding physically and mentally. Establishing ICM as a primary speciality would disqualify intensivists from working in another specialisation, whereas the ‘particular qualification’ approach allows them to return to their ‘mother disciplines’, rotate back there for a period or allow those working in the mother discipline to participate in the on call system.

All parties involved in ICM in European countries should seek an open-minded discussion with the aim of harmonising the required competencies in order to develop ICM and achieve better treatment and safety for future patients in intensive care.

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References

1. Rubulotta F, Moreno R, Rhodes A (2011) Intensive care medicine: finding its way in the “European labyrinth”. Intensive Care Med 37:1907–1912. doi:10.1007/s00134-011-2391-1

2. De Lange S, Van Aken H, Burchardi H; European Society of Intensive Care Medicine; Multidisciplinary Joint Committee of Intensive Care Medicine of the European Union of Medical Specialists (2002) European society of intensive care medicine statement: intensive care medicine in Europe—structure, organisation and training guidelines of the multidisciplinary joint committee of intensive care medicine (MJCICM) of the European union of medical specialists (UEMS). Intensive Care Med 28:1505–1511

3. Van Aken H, Mellin-Olsen J, Pelosi P (2011) Intensive care medicine: a multidisciplinary approach! Eur J Anaesthesiol 28:313–315

VI Reunión de la Sección de Cuidados Intensivos de la SEDAR

La VI Reunión de la Sección de Cuidados Intensivos de la SEDAR tendrá lugar los días 10, 11 y 12 de Mayo de 2012 en Madrid.
Podéis acceder en http://www.evenir.es/CuidadosIntensivos2012/
Os esperamos.

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.