[JAMA述评]:重症医学教育及认证的标准(英文) | 中国病理生理学会危重病医学专业委员会
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[JAMA述评]:重症医学教育及认证的标准(英文)
2017年10月20日 事件●关注, 学会动态 暂无评论

【编者按】:早在2009年,重症医学在中华人民共和国学科分类(GBT 13745-2009)中被列为临床医学二级学科,同时,当时的卫生部也将重症医学科列为医疗机构一级诊疗科目。但是,将近十年过去了,有关重症医学究竟是专科抑或亚专科的争论仍然不绝于耳。2014年,住院医师规范化培训制度在全国范围内实施。遗憾的是,重症医学科并未获得住院医师规范化培训的资质。2016年,专科医师规范化培训试点工作宣告开始,重症医学的规培工作再度成为争论的焦点之一。

编者认为,在学术观点层面进行争论,对于大家更加深入地了解重症医学的专科特点及其与其他专科的关系大有裨益。然而,我们不无遗憾地看到,这种本应停留在学术层面的争论不恰当地受到了行政权力的粗暴干预...

一种观点认为,我们应当照搬或效仿美国的重症医学培训制度。然而,相信重症医学的同道都非常清楚,美国重症医学的培训制度其实是落后的。

我们在此全文刊登2011年JAMA发表的一篇述评(一周后我们会刊登这篇文章的中文译文)。字里行间反映了美国的重症医学同道对于这一问题的反思。希望这篇文章对于国内的部分同道或许也是一种警醒...

COMMENTARY

Standards for Education and Credentialing in Critical Care Medicine

Lewis J. Kaplan, Andrew D. Shaw

JAMA 2011; 305: 296-297

THE PROVISION OF INTENSIVE CARE TO PATIENTS IN THE throes of life-threatening acute illness is one of the most important and most expensive parts of US health care. Today, adults in the United States are increasingly likely to receive intensive care unit (ICU) care compared with previous generations, with the greatest ICU resource use occurring among older patients and those at the end of life.1 Several million individuals are admitted to ICUs in the United States each year at a cost approaching 1% of the nation’s gross domestic product.2,3 A large body of evidence suggests that the likelihood a patient will survive an episode of critical illness is exquisitely dependent on how the ICU is staffed.4 In particular, care led by physicians trained and certified in critical care medicine (CCM) is strongly associated with improved odds of survival. In the rest of the developed world, ICUs are staffed exclusively by physicians trained in CCM. However, in the United States, only a third of patients in the ICU are managed by critical care physicians.5 There is no coordinated effort to train an expanded workforce of CCM physicians.

In the United States, CCM is recognized neither as an independent discipline such as surgery, internal medicine, or anesthesiology, nor as a conjoined subspecialty with uniform education, training, and credentialing. Rather, there are now 6 separate adult intensive care training pathways following residency training in anesthesiology, emergency medicine, internal medicine (either as critical care alone or jointly with training in pulmonary medicine), neurology, and surgery, leading to an array of training programs with separate credentialing criteria. No other medical subspecialty has such an inconsistent approach.

Critical care medicine seems to be moving away from uniform standards even as it matures as a specialty. Critical care medicine arose in the United States during the 1960s just as ICUs emerged. In the United States, CCM has been regarded as a “niche” specialty in that training is undertaken by a minority of physicians within a primary specialty.6 In this way, CCM training is viewed as a supplement to primary specialty training to provide care for the most critically ill patients who could already be classified into traditional specialty categories. On the surface, this system of added qualification to a base specialty might seem advantageous in terms of acquiring subspecialty knowledge and standardization of disease treatment. However, such a system creates confusion among practitioners and patients and establishes a barrier to practice and credentialing standardization as each specialty applies its own approach to a given disease process. Moreover, the current approach may discourage trainees from CCM specialization and exacerbate the shortage of intensivist physicians.

The 2003 residency work-hours restrictions have further illustrated the need for trained intensivists. While attempting to balance trainee service and education needs to improve patient safety, the restrictions inadvertently created a care void chiefly filled by other clinicians such as physician assistants and advanced practice nurses.7 This strategy reduces patient exposure to direct physician care and establishes a cadre of clinicians in need of leadership, mentorship, and education in the delivery of critical care.

With increasing need for ICUbeds, patients requiring ICU admission are often cared for in the emergency department or the general ward until an ICU bed becomes available. In some cases, admission to the ICU may be substantially delayed, prompting the development of ICU outreach teams. Exacerbating this overcrowded situation is the increased frequency of transfers from outlying institutions to tertiary centers based on patient acuity and complexity or lack of specialist availability. Lack of insurance or underinsurance further compounds these problems with the looming concern about absent or insufficient compensation for acute illness complication management, perhaps leading to increased pressure to transfer complex patients to already overburdened tertiary referral centers. Indeed, many ICUs already have mixed practices in which surgical patients are cared for by surgery, anesthesiology, internal medicine, emergency medicine, and even obstetrics-gynecology intensivists as single specialty care is impractical from a workflow perspective.

Previously, adult CCM training was restricted to primary specialties, such as internal medicine and surgery. However, many specialties have difficulty filling theirCCMtraining slots. Of available surgicalCCMslots, only approximately 50% have filled during the residency match process for each of the past 3 years; anesthesiology and internal medicineCCMslots have had similar issues and some programs have been discontinued because of lack of applicants.1 Perhaps the time is now right for cross-specialty training and accreditation to come to the fore. For instance, an anesthesiologist may train in surgical CCM and then receive a certificate of added qualification under the anesthesiology pathway and vice-versa.1 Perhaps more importantly, physicians who complete any medical specialty training program may be trained in neurocritical care, a true cross-specialty training and certification event.8 These developments support the concept that the core principles of CCM exist outside of physician specialty and instead hinge on key care priorities.

Standardizing medical education and care is a top priority for the US health care system. However, nowhere is care more heterogeneous than in the ICU, where differences in physician training and credentialing, governed by at least 5 specialties, serve as barriers to standardization. This situation is potentially rather confusing to patients, trainees, and other health care professionals, who may be unsure what to expect from the diverse practitioners who identify themselves as intensivists.

These observations raise several questions related to training, education, certification, and credentialing. If the key aspects of CCM are not specialty unique, it is possible to envision a single core set of cognitive domains that all training programs address in an identical fashion, a single specialty-independent CCM certification process, and a single set of credentialing requirements. Such an approach exists in the European Union with streamlined training articulated by the Competency-Based Training in Intensive Care Medicine (CoBaTrICE) program.9 CoBaTriCE hinges on identifying, teaching, and assessing core competencies as a means of education and certification. Thus, in a specialty independent fashion, such certification couples didactic knowledge mastery with the demonstrated ability to successfully employ that knowledge in a defined setting. Moreover, this program provides a continuously updatable platform from which to pursue core competency recredentialing.

An integrated approach to CCM training would provide an economy of scale for the educational program in which multiple specialty trainees receive didactic education together. This approach reduces overall faculty burden, fosters interspecialty education, and establishes a common ground for care. Furthermore, integrated training would allow faculty and trainees to learn from counterparts outside of their base specialty. Anesthesiologists can provide expertise in airway management while surgeons address resuscitation and internists educate about managing comorbid medical conditions. The challenge now exists for certifying organizations to adopt a single CCM examination. Critical care medicine is no longer the purview of only a few specialty-trained individuals just as intensive care is no longer a rarity. Critical care medicine is a rapidly growing discipline but remains understaffed, expensive but rewarding, specialty-linked but specialty boundless, and seeks the highest-quality care for critically ill patients. It is time for CCM to mature into a seamless system of care delivery, encompassing all its parent specialties, just as its founders intended.

REFERENCES

1. Milbrandt EB, Kersten A, Rahim MT, et al. Growth of intensive care unit resource use and its estimated cost in Medicare. Crit Care Med. 2008;36(9): 2504-2510.

2. National healthcare expenditures aggregate, per capita amounts, percent distribution and average annual percent growth, by source of funds: selected calendar years 1960-2008. US Dept of Health and Human Services, Centers for Medicare & Medicaid Services. http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf. Accessed March 26, 2010.

3. The critical care workforce: a study of the supply and demand for critical care physicians: report to Congress. US Dept of Health and Human Resources. http://www.bhpr.hrsa.gov/healthworkforce/reports/criticalcare/default.htm. Accessed October 18, 2010.

4. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162.

5. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient: current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770.

6. Graduate Medical Education Data Resource Book: 2008-2009. http://www.acgme.org/acWebsite/dataBook/dat_index.asp. Accessed March 26, 2010.

7. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008; 36(10):2888-2897.

8. Neurocritical care certification. http://www.ucns.org/go/subspecialty/neurocritical/certification. Accessed October 18, 2010.

9. CoBaTriCE: an international competency-based training programme in intensive care medicine. http://www.cobatrice.org. Accessed March 26, 2010.

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