322
COMMENTARIES
Gunn, Grenvik • CRITICAL CARE CERTIFICATION
Emergency Medicine and Critical Care Certification
A
s early as 1543, in his classical work De Humani Corporis Fabrica, Vesalius described an experiment in which an animal was kept alive by rhythmic insufflation of air into the trachea.1 This is perhaps the first scientific attempt to maintain life by artificial means. Florence Nightingale was the first health care professional to utilize an intensive care unit (ICU) for management of the sickest patients during the Crimean War (1854– 1856). During World War II, shock wards were established to resuscitate soldiers injured in battle and after major surgery. The nursing shortages that followed World War II forced the grouping of postoperative patients in recovery rooms to allow for close observation and intensive therapy. The obvious benefits in improved patient care would soon result in the spread of postoperative recovery rooms to nearly every hospital. However, modern ICUs did not appear in European and American hospitals until the polio epidemics of the 1950s, where tracheostomy and prolonged ventilatory support were used to support patients in the most severe cases.2 Peter Safar at Baltimore City Hospital initiated the first physician-staffed ICU providing 24-hour-a-day life support in 1958.3 Because lifethreatening illness can result from a wide variety of medical, surgical, or traumatologic problems, it became clear that many different professionals would need to be involved in the management of critically ill patients. In 1970, an internist/cardiologist (Max Harry Weil), an anesthesiologist (Peter Safar), and a surgeon (William Shoemaker) together with 25 other specialists of different disciplines founded
the Society of Critical Care Medicine. They defined critical care medicine as ‘‘the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury.’’4 Many have criticized the term critical care medicine; perhaps most notably Peter Safar, as critical care not only takes place in the ICU, but begins at the onset of critical illness or at the scene of life-threatening trauma.5 Modern critical care continues during transportation to a selected hospital capable of managing the critically ill or injured patient. With resuscitation and life support already in progress, a rapid pursuit of diagnosis or cause of the life-threatening condition is necessary and frequently begins in the emergency department (ED). The patient may then go to the operating room or directly to an ICU. Mortality is high among these patients and death may occur in any phase of the management. When and if these critically ill patients are discharged from the ICU, they may end up on regular hospital wards. However, there are also an increasing number of patients transferred to intermediate care or stepdown units for prolonged intensive care and mechanical ventilation, when the critical illness may have reached a chronic state with a more stable condition. During recent years, in the United States and other countries (e.g., Austria), EDs at major tertiary care hospitals have been introducing short-term ICUs or observation units.6–8 Many of the patients treated in these ED/ ICUs may not need formal admission to the hospital if immediate diagnosis and therapy lead to timely stabilization and recovery.9–11 Because critical care be-
gins when the critically ill patient first comes in contact with the health care system and because many EDs currently utilize short-term ICUs or observation units, many emergency medicine (EM) specialists would benefit from critical care medicine (CCM) training. They should be offered the opportunity to become certified subspecialists in this field. Indeed, the American Board of Emergency Medicine (ABEM) has repeatedly requested the right to examination and certification in CCM, a privilege that so far ABEM has been denied by the American Board of Medical Specialties (ABMS). In the 1980s, efforts were made in the United States to provide a joint CCM certification exam for those physicians trained and practicing in this field.12 However, the four major disciplines involved in critical care at that time (anesthesiology, internal medicine, pediatrics, and surgery) decided to develop their own subspecialty exams in critical care, and at least temporarily the door was closed to American physicians of other disciplines to obtain certification in CCM as a subspecialty. The current system leaves a number of other physicians such as neurosurgeons and neurologists with special interest in CCM without the right for certification in this field. This is unfortunate because many specialized neurological and neurosurgical ICUs already exist. Although the need for CCM subspecialty training and certification for EM and other specialists exists, the current system does not allow them to obtain subspecialty certification in CCM. Recently, the American Board of Internal Medicine (ABIM) offered a compromise through which physicians may obtain combined training in EM, internal medicine, and CCM.13 Such training will take place over six years, instead of the
ACADEMIC EMERGENCY MEDICINE • April 2002, Volume 9, Number 4 • www.aemj.org
seven that would normally be required to complete all three. These physicians will be permitted to sit for the CCM exam provided by the ABIM. This may be an indication that in the future we will see possibilities for EM physicians with appropriate additional CCM training to become CCM-certified by an ABEM examination. The current model of CCM training as a subspecialty in the United States is certainly not the only valid approach. In Europe, the examination is available through the European Society of Intensive Care Medicine to anyone completing a base specialty certification and two years of additional training in CCM.14 In the United States, the ABMS could provide such an exam. In addition, there are other countries, (e.g., Japan) that have chosen to combine EM and CCM, commonly placing the ICU in the ED. Academic departments of CCM at American medical schools are currently being established. In the future, this might lead to CCM primary board certification in the United
States, as is already the case in Spain. Solutions to the CCM dilemma vary in different parts of the world, and the American system is not necessarily the best one. Nevertheless, we live in an era of rapid change, which is certainly true in medicine. Therefore, future changes are likely in CCM examination and certification as well.—SCOTT GUNN, MD (
[email protected]), and AKE GRENVIK, MD, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA Key words. critical care; certification; emergency medicine; subspecialty.
References 1. Vesalius A. De Humani Corporis Fabrica. Basel, 1543. 2. Ibsen B. The anesthetist’s viewpoint on treatment of respiratory complications in poliomyelitis during the epidemic in Copenhagen, 1952. Proc R Soc Med. 1954; 47:72–4. 3. Safar P, DeKornfield T, Pearson J, Redding J. Intensive care unit. Anesthesia. 1961; 16:275–84. 4. Weil MH. The Society of Critical Care Medicine, its history and its destiny. Crit Care Med. 1973; 1:1–4. 5. Safar P. The critical care medicine
323 continuum from scene to outcome. In: Parillo JE, Ayres SM (eds). Major Issues in Critical Care Medicine. Baltimore: Williams and Wilkins, 1984. pp 71–84. 6. Counselman FL, Schafermeyer RW, Garcia R, Perina DG. A survey of academic departments of emergency medicine regarding operation and clinical practice. Ann Emerg Med. 2000; 36:446– 50. 7. Nguyen HB, Rivers EP, Havstad S, et al. Critical care in the emergency department: a physiologic assessment and outcome evaluation. Acad Emerg Med. 2000; 7:1354–61. 8. Bur A, Mullner M, Sterz E, Hirschl M, Laggner A. The emergency department in a 2000-bed teaching hosptial: saving open ward and intensive care facilities. Eur J Emerg Med. 1997; 4:19–23. 9. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001; 110:274–7. 10. Ross MA, Naylor S, Compton S, Gibb KA, Wilson AG. Maximizing use of the emergency department observation unit: a novel hybrid design. Ann Emerg Med. 2001; 37:267–74. 11. Grenvik A. Alternative modes of financing health care technology. Singapore Med J. 2001; 30:222–5. 12. Grenvik A, Leonard JJ, Arens JF, Carey LC, Disney FA. Critical care medicine. Certification as a multidisciplinary subspecialty. Crit Care Med. 1981; 9: 117–25. 13. American Board of Internal Medicine. Internal Medicine/Emergency Medicine/Critical Care Medicine Training Guidelines. www.abim.org; 2001. 14. European Society of Intensive Care Medicine. European Diploma in Intensive Care. www.esicm.org; 2001.
