[编者按]：重症医学虽然起源于美国，但其发展却历经磨难，至今仍然步履维艰。同在北美的加拿大却走过了不同的道路。从30多年前两国学者的述评中，我们不仅能够了解到双方的观点，更重要的收获应当是，学科之间只有相互协作才能发展，固步自封并非解决问题之道...
Training and Certification of Critical Care Medicine in the United States
Max Harry Weil, William C. Shoemaker, Eric C. Rackow
Chest 1988; 93: 1122-1123
Drs. E. Garner King and William Sibbald are internationally recognized scientific and professional leaders in critical care medicine. Their guest editorial in this issue entitled “The Territorial Imperative” projects the thoughtful concern of compassionate Canadian colleagues with the way in which we have approached the formal training and subspecialty certification process in critical care medicine in the United States. They view the separation of the training and certification process between specialists in internal medicine, general surgery anesthesiology, and pediatrics as violating a more rational multidisciplinary approach which would better serve the interests of optimal patient care. They confirm that critical care medicine is a legitimate discipline with an appropriate body of knowledge; that it differs from the traditional “vertical” organ-based specialties in that it is “horizontal” in the sense that it concerns itself with life-threatening and multiple organ impairment. Accordingly, care of the critically ill, by definition, is a multidisciplinary commitment.
These Canadian leaders address both the organization and the educational processes which would be likely to optimize the delivery of critical care services by well-qualified experts. They reluctantly conclude that the territorialism which they discern cannot help but violate the fundamental multidisciplinary commitment. Why, they ask, is critical care medicine separately accommodated by four essentially independent specialty boards and possibly more to come? Why is the training and certification process for critical care specialists, including the examination, separate and unique for each specialty? They are led to conclude that it is primarily economically driven or, as they say, a holdover of the guild system of the Middle Ages. They point to it as a system which was designed to preserve the territorial prerogatives and, by implication, the competitive economic interests of the specialties. Though both of these leaders are well-qualified chest physicians, they recognize that other subspecialists may be well-qualified to provide critical care. They hold that such care may be provided in a medical, surgical or other specialty intensive care unit. Indeed, they hold to the concept that both medical and surgical specialists, including anesthesiologists and pediatricians, may be trained and capable of providing such services.
We can find little fault with the carefully reasoned position taken by our Canadian colleagues and certainly not with the more ecumenical option adopted by the Canadian Royal College of Physicians and Surgeons.1Moreover, the Society of Critical Care Medicine has traditionally favored such a multidisciplinary approach.2,3 The reality that critical care medicine is now separately certified by four individual boards was a pragmatic rather than an optimal quid pro quo. It reflected the disparate viewpoints among specialists and subspecialists and especially chest physicians who were represented in the decision-making of the independently constituted specialty boards.
Those who practice critical care medicine are likely to acknowledge that critically ill patients who have severe and acute life-threatening illnesses involving more than one organ or organ systems should be cared for by physicians who have a multidisciplinary critical care orientation and who maintain continuing presence at the bedside of the critically ill or injured. There may be room, however, in the case of the patient with end-stage single organ failure such as chronic congestive heart failure after long-standing coronary artery disease, terminal respiratory failure in patients with chronic obstructive pulmonary disease or during postoperative management of carcinomatosis for organ-based specialists who are not specifically trained in critical care, to maintain primacy. Yet, this is likely to be a minority of patients. There is also little doubt that the special knowledge and skills of “vertical” subspecialists should accrue to the benefit of the critically ill patient when either expert opinions or procedural interventions make such appropriate.
Our colleagues in Canada have resolved these territorial issues in a commendable manner.4 They have risen above what they term fragmented territoriality, which was the barrier to a unified training and certification process in our own country. The Canadians have stressed the commonality of training and service and thereby avoided fragmentation in favor of cooperative and collegial multidisciplinary training programs and practice arrangements unimpeded by subspecialty constraints.
For the time being, the die is cast and the accreditation formalities in the United States are proceeding in their predetermined fashion. Perhaps we have lacked that Solomonic wisdom which would have prevented us from slicing up the baby. Moreover, we have much to learn from our Northern neighbors. Nevertheless, we have previously pointed to the fact that the opportunity for collaboration between the established boards, the specialty societies interested in critical care medicine, and the Society of Critical Care Medicine itself are very good.5 It is proper for us to pay heed to the gentle yet potent message communicated to us by our Canadian neighbors. We therefore would do well to promote collaboration, beginning with a joint examination process among the boards which presently certify subspecialists in critical care medicine. We shall also want to assure that a critical care specialist who is subspecialty certified by one board will not be constrained if appropriately qualified by experience and training when he serves other disciplines.
Finally, those of us who were testimonial to the gestation and birth of critical care medicine itself take great pride in the reality that critical care medicine has come of age. The very fact that we have reached maturity to the level that we can establish a dialog on the certification process represents an over-riding good. We now look to the continuing evolution of critical care medicine South of the Canadian border, such that it is increasingly integrated to serve appropriately as a multidisciplinary asset alongside the traditional specialties and subspecialties.
