Nandan Gautam and Julian Bion

Chapter Outline

Training Aspirations for Intensive Care Medicine

The purpose of any medical education program should be to integrate knowledge, skills, attitudes, and behaviors within a sound ethical and professional framework that encourages reflective life long learning, with the aim of producing competent and caring practitioners who possess both team-working and leadership capacities. Achieving this objective requires a firm focus on the needs of patients and confident and effective structures and processes for training and education. The American College of Critical Care Medicine states,¹ “Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.” To this statement one could add: using the knowledge and resources of a multiprofessional team and involvement of patients and caregivers.

The Training Environment

Training and service are necessary companions. In the last 20 years, health systems worldwide have seen that patients’ expectations of safe and reliable health care are not always satisfied.2,3 It is reasonable for patients to expect that their care should be delivered by fully trained specialists and not by less experienced individuals or those in training grades. However, this expectation is made difficult to satisfy by cost pressures, rationing, increased throughput, staffing limitations, and reduced hours of work for trainees.^4,5 These challenges are a particular problem for acute and emergency care, including critical care,⁶ but it is in precisely these areas that some of the most innovative solutions can be found.

Physician assistants or extended-role nurse practitioners are now active in many roles. In ICM, the United Kingdom has developed a program for advanced critical care practitioners⁷ derived from the physicians’ Competency-Based Training in Intensive Care Medicine (CoBaTrICE) program. Critical care and outreach, medical emergency teams,⁸ and the United Kingdom’s hospital at night and 24/7 teams⁹ all involve senior nurses with diagnostic and management training. In the United States, growth of the hospitalist movement into a new specialty demonstrates how the clinical demands of acutely ill patients can have an impact on training and education.¹⁰ The National Organization of Nurse Practitioner Faculties has developed a national program of competencies that includes diagnostic algorithms and treatment based on protocols,¹¹ and many of the competencies are centered around management of acutely ill or physiologically unstable patients. Acutely ill patients are thus necessarily cared for by multiple teams involving physicians, nurses, and allied health care professionals. Such teams have rapidly changing membership, and colleagues often do not know each other well. Accurate and comprehensive clinical handoffs/handovers need to be standardized in order to ensure continuity of care. This care needs to be supplemented by objective processes that pick up measures of physiologic deterioration, escalate concerns in a timely and appropriate manner, and can call upon the best person at the right time, every time. Training to acquire these complex skills in the acute and emergency care environment must be embedded in undergraduate curricula for all health care professionals.^12,13

Current Training in Intensive Care Medicine

The emergence of critical care medicine from the poliomyelitis epidemics of the 1950s was underpinned by developments in cardiorespiratory pathophysiology and organ system support led by anesthesiology and respiratory medicine. The safety record of anesthesiology combined with better technology and drugs has enabled increasingly complex surgery and has extended the role of the anesthetist into postoperative intensive care. Respiratory physicians also have a traditional association with critical care, particularly in the United States, where they remain the most numerous specialists within critical care medicine. Principles of ICM are a mandatory component of many specialty training programs worldwide, but the extent to which this training is recognized as specialist ICM training varies. Specialists from other primary disciplines such as surgery and internal and emergency medicine (and pediatrics) participate in critical care, but with varying degrees of access to, or inclusion of, competencies in ICM.

In a survey of 41 countries carried out by the CoBaTrICE Collaboration¹⁴ under the aegis of the European Society for Intensive Care Medicine (ESICM), 54 different ICM training programs were identified (37 within the European region) that ranged in duration from 3 months to 6 years (most frequently 2 years). Entry criteria were significantly different between some countries with regard to the structure and format of the training program. Nursing surveys demonstrate similar diversity in their training programs. The CoBaTrICE survey was updated for European Region countries in 2009,¹⁵ and demonstrated that although progress had been made on convergence in speciality status and shared competencies there were still significant deficiencies in standards for assessment, quality assurance, and infrastructure support for training. Currently 10 European Region countries use the harmonized CoBaTrICE competencies.

Most countries observe one or more of the following models of ICM training: primary specialty (critical care training directly after medical school), subspecialty (critical care training as an exclusive component of a primary discipline), or supraspecialty training (a common critical care training shared by multiple primary specialties).

In primary specialty training, ICM is regarded as a fully independent specialty with a separate training program accessed directly from the undergraduate level or from a common stem at internship or residency. This training may be undertaken in addition to a complementary primary specialty, commonly anesthesiology or internal medicine.

Subspecialty refers to ICM training within a parent specialty and exclusive to it. In the majority of such systems, ICM training can be accessed only through anesthesiology. Other disciplines, such as internal medicine and surgery, may offer their own subspecialty training in ICM. These separate routes may be related to each other but are administered differently and often have different components. Certification will reflect the base specialty but often documents subspecialty status also.

Supraspecialty training is the most common model. Here, a primary specialty is chosen and intensive care training is grafted onto it, either in a modular or in a single-block format. Certification in ICM requires certification in the primary specialty also. It allows a number of specialties to access common ICM training. In practice, however, the specialties remain predominantly anesthesiology, internal medicine (adult and pediatric), and respiratory medicine. ICM is now a primary speciality in Spain, the United Kingdom, Switzerland, Australia, and New Zealand; all except Spain also offer dual certification in ICM and another primary speciality.

Outside the CoBaTrICE program and those countries that have adopted it, few national programs define the outcomes of training explicitly in terms of the competencies expected of a specialist in ICM. There is tacit acknowledgment that the terms “attending,” “consultant,” and “specialist” may have administrative and logistic equivalence within individual countries and that a “good” specialist in one country is likely to be as well equipped with knowledge and skills as a good specialist in another, but there is little evidence to prove this, whereas there is solid evidence that standards of assessment and quality assurance vary widely between countries and even between different speciality programs within countries.¹⁵

Specialist status in all these schemes is obtained through some combination of time spent in the program, competency-based assessments, case reports, submission of diploma theses, oral (viva voce) examination, and clinical examination. There does not as yet exist an enforced recertification process specifically for ICM in any country, nor is there an agreed-upon standard for benchmarking intensive care units or training programs against international peers, though such standards are now being developed.¹⁶ For example, the United Kingdom has now established a multicollegiate Faculty of Intensive Care Medicine responsible for the new primary specialist training program in ICM, and for standards of revalidation and peer review.^17,18

Competency-Based Training

Competencies are a method for describing the knowledge, skills, attitudes, and behavior expected of specialists in terms of what they are able to do. Several national regulatory bodies for physicians have started to modify their training programs from syllabus-based, examination-driven systems to programs based on competencies assessed in the workplace, particularly the United Kingdom, Canada (using the CanMEDS framework¹⁹), and the United States. The challenge for trainers and trainees is to develop robust methods for workplace-based assessment and to create the necessary flexibility within training programs to allow time-based training to be replaced by programs in which trainees acquire competencies at different rates. This has been made more difficult by limitations on working hours.^4,5 The resultant friction between service and training has led to poor use of assessment tools and an increasing belief that excellence in some has been sacrificed for a basic level of competence in many.²⁰

The CoBaTrICE Collaboration was formed in 2003 to harmonize standards of training in ICM internationally, first by defining outcomes of specialist ICM training and then by developing guidance and standards for assessment of competence and program infrastructure and quality assurance.21,22 The underlying principle of this initiative was the concept that an ICM specialist trained in one country should have the same core skills and abilities as one trained in another, thereby ensuring a common standard of clinical competence. This follows the European Union ethos of free movement of professionals and mutual recognition of medical qualifications between member states.²³ Competency-based training makes convergence possible by defining the outcomes of specialist training—a common “end product”—rather than enforcing rigid structures and processes of training. A minimum standard of knowledge, skills, attitudes, and behavior is defined a priori and applied to existing structures and processes of training; acquisition and assessment of competence occur during training in the workplace.

Defining Core Competencies

The CoBaTrICE project has used consensus techniques—an extensive international consultation process using a modified online Delphi involving more than 500 clinicians in more than 50 countries, an eight-country postal survey of patients and relatives, and an expert nominal group—to define the core competencies required of a specialist in ICM.21,24 These competencies have been linked to a comprehensive syllabus, relevant educational resources, and guidance for the standardized assessment of competence in the workplace via a dedicated website.²² Since its launch in September 2006, 10 national training programs have adopted CoBaTrICE, and others have made use of the materials. In 2008, the second phase of the project developed international standards for national training programs in ICM,¹⁶ and further refined the methods of assessment of competence. The implementation and long-term evaluation of the CoBaTrICE program will be necessary to assess its impact on an individual’s competence and harmonization of ICM training. In the United States, a multisociety initiative has used a similar methodology to the CoBaTrICE program to create common competencies.²⁵

Evolving Professional Roles: Implications for Training

The CoBaTrICE Delphi demonstrated the importance that intensive care clinicians attach not only to the acquisition of procedural technical skills but equally to aspects of professionalism—communication skills, attitudes and behavior, governance, team working, and judgment.²⁴ The intensivist is akin to an “acute general practitioner,” a family doctor with enhanced role in acute medicine, physiology, diagnostics, palliative care, research, ethics, and with added technical ability. Most importantly they are the team leaders and orchestrators (and providers) of care, and their competencies must therefore include these team-management, integration-of-care skills. Competency-based training makes this possible by explicitly identifying which skills are shared in common and which are peculiar to specific disciplines. Thus, although weaning from ventilation,²⁶ instigation of renal replacement, nutritional support, prophylaxis for venous thromboembolism, and chest pain management pathways,²⁷