[JAMA述评]:重症医学教育及认证的标准(中文) | 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(中文)
2017年10月27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发表的一篇述评的中文译文(一周前我们刊登这篇文章的英文原文)。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.

向罹患致命的急性疾病的患者提供重症医疗是美国医疗最为重要、也是花费最多的部分之一。与前几代人相比,今天美国的成年人在ICU中接受治疗的机会大幅增加,而老年患者以及临终患者占用了最多的ICU资源。美国每年有数百万人收入ICU,总花费接近国内生产总值的1%。大量证据表明,罹患危重病的患者能否存活,高度依赖ICU的人员配备。尤其需要指出的是,由经过重症医学专科培训和认证的医生提供治疗,与生存率的改善密切相关。在其他发达国家,ICU几乎完全由经过重症医学专科培训的医生管理。然而,在美国,只有1/3的ICU患者由重症专科医生负责诊疗。而且,在增加重症医学专科医生人员方面并没有形成协调一致的机制。

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.

在美国,重症医学并没有像外科、内科或麻醉一样成为一门独立的学科,而且也不是有着统一教育、培训及资格认证的综合性亚专科。相反,在麻醉、急诊内科、内科(包括单独的重症医学或与呼吸病学联合培训)、神经内科与外科住院医师培训之后,目前有6种相互独立的途径培训成人重症医学专科医师,因而导致存在一系列的认证标准完全不同的培训项目。没有其他任何医学亚专科具有如此像不同的培训途径。

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.

尽管重症医学逐渐向专科过渡,但似乎越来越背离了统一标准。20世纪60年代随着ICU的出现,重症医学得以发展。在美国,重症医学被认为是一种“细分(niche)”专科,由已具有主要专科资质的少数医生接受培训。因此,重症医学的专科训练就被视为主要专科培训的补充,以便针对已经划分到传统专科范围的最危重患者提供医疗。表面上,在原有专科基础上增加额外的资格认证这一体系,在获取亚专科知识以及疾病的标准化治疗方面似乎具有优势。然而,这一体系给医生和患者都带来困惑,同时,由于各个专科对于同一种疾病进程均有其诊治途径,因此,这一体系为医疗实践和资格认证的标准化制造了障碍。此外,现阶段的做法并不能鼓励医生接受重症医学专科培训,从而加剧了重症医学专科医师的人员短缺。

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.

2003年起,对住院医师工作时间的限制政策进一步突显了对经过培训的重症医学专科医师的需求。尽管这种努力旨在平衡学员服务及教育需求以改进患者安全,但这些限制政策无意中形成了医疗的缺口,而这一缺口主要由医生助理及高年资护士填补。这一策略减少了医生对患者的直接照顾,同时,上述人员在提供重症医学方面也需要领导、指导和教育。

With increasing need for ICU beds, 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.

随着对ICU床位需求的增加,需要收入ICU的患者通常在急诊科或普通病房接受治疗,直到有了空余的ICU床位为止。在某些情况下,这可能造成收入ICU大幅度延迟,因而推动了ICU快速反应小组的出现。基于患者病情的急迫性及复杂性,以及缺乏专科医生,边远的医院向三级医院转诊的情况越来越多,进一步加剧了过度拥挤的状况。在上述问题的基础上,保险的缺乏或不足可能进一步加剧了医生对于治疗急性病并发症所需补偿的缺位或不足的潜在担心,这可能导致将病情复杂患者转诊至业已超负荷运转的三级医院的压力增加。事实上,很多ICU已经出现外科患者由外科、麻醉科、内科、急诊科甚至妇产科的ICU医生共同管理的情况,这是因为从工作流程的角度进行单一专科管理不切实际。

Previously, adult CCM training was restricted to primary specialties, such as internal medicine and surgery. However, many specialties have difficulty filling their CCM training slots. Of available surgical CCM slots, only approximately 50% have filled during the residency match process for each of the past 3 years; anesthesiology and internal medicine CCM slots 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.

既往,成人重症医学的专科培训仅限于某些主要专科(如内科和外科)。然而,很多专科都难以填补其重症专科培训的空位。过去三年间,在住院医师适配(match)过程中,每年外科重症医学培训项目仅招收到约50%的培训学员;麻醉及内科重症专科培训也存在类似问题,由于没有住院医师申请,一些培训项目已经终止。现在也许是跨专科培训和资质认证体系脱颖而出的时候了。例如,麻醉科医生可以参与外科重症医学的专科培训,然后在麻醉学专业下获得额外的资质认证,反之亦然。可能更为重要的是,完成任何医学专科培训的医生都可以接受神经重症的培训,这是一个真正的跨专科培训及资质认证过程。这些发展支持了以下理念,即重症医学的核心原则其实脱离于医生的专科之外,而与关键的治疗措施密切相关。

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.

医学教育和治疗的标准化是美国卫生体系的优先考虑。然而,ICU医疗的异质性比其他任何专科都更为突出,由至少5个专科负责的医生培训及资质认证的差异已经为上述标准化设置了障碍。这种情况造成了患者、学员甚至其他医务人员的困扰,从自称为重症医学专科医生的不同人员那里究竟能够得到何种治疗,他们对此并无把握。

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.

上述现象对于培训、教育、资质认证等提出了问题。如果重症医学的核心内涵并非某一个专科所独有,那么就可能制订单一的核心认知内容,以保证所有的培训课程以相同的方式进行,这是一种独立于任何一个专科的重症医学认证过程,而且有单一的认证要求。这种做法在欧盟已经付诸实施,欧盟将精简后的重症医学专科培训称之为CoBaTrICE。CoBaTrICE将鉴别、教学与评估的核心技能作为教育和认证的手段。因此,通过这种不依赖于任何一个专科的方式,上述认证兼顾了教学知识的掌握以及在特定场景下成功应用知识的能力。而且,这个项目还可以提供一个不断更新的平台,以供核心技能的再次认证。

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.

重症医学专科培训的统一方式也是更为经济的教育方式,来自多个专科的学员可以共同接受教学。这种方法可以减少教师的负担,促进跨学科的教育,并建立医疗的共同基础。而且,统一培训还可以使教师和学员能够从其他专科获益。麻醉科医生提供气道管理方面的专业意见,外科医生强调复苏,而内科医生则教授如何管理合并症。目前,存在的挑战是资质认证机构能否采用单一的重症专科考试。正如ICU不再稀有,重症医学也不再限于少数专科培训的人员。重症医学是一个快速发展的学科,但人员仍然不足,费用高昂但回报巨大,与专科相关但并不局限于某一专科,追求为重症患者提供最高质量的医疗服务。正如重症医学开创者所希望的那样,现在是重症医学成长为提供包括所有其他专科在内治疗的无缝体系的时候了。

翻译:北京协和医院  秦含玉

REFERENCES

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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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