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[Chest旧文]:地域法则(中译文)
2020年06月19日 事件●关注, 学会动态 暂无评论

[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...

The Territorial Imperative

E. Garner King, W. J. Sibbald

Chest 1988; 93: 1121-1122

As two Canadians who have been involved in critical care in North America for many years, we are uncomfortable in writing this invited editorial. We hope that our American colleagues will forgive us as we critically glance to the south, to comment on the organization and educational process associated with the continuing growth of critical care in the United States. It has been with friendly concern that we have witnessed a progressive balkanization of critical care, as a discipline, in the United States. It would seem that the multidisciplinary commonality of purpose displayed throughout critical care's infancy in the 1960s and 1970s has now given way to potentially divisive territoriality and turf issues in the 1980s. It is our gratuitous opinion that, if left unattended, this current process may ultimately lead to problems in patient care, in resident training, and in the reasonable allocation of dwindling health care resources.

作为在北美从事重症医学多年的两位加拿大人,我们对撰写这篇特邀评论感到非常忐忑。我们希望美国的同行可以原谅我们,因为我们以批判性地态度,对美国重症医学发展过程的组织形式和教育流程加以评论。我们友善的关注并见证了美国重症医学作为一门学科,逐渐巴尔干化(割据分裂化)的发展过程。在1960年代至1970年代,重症医学发展初期表现出的多学科协作特性,到了1980年代,逐渐转变为潜在的各个分裂的领域问题。我们多虑地认为,如果不加注意,当前这种演变最终可能带来患者治疗,住院医师培训和合理分配日益减少的医疗资源等方面的问题。

Critical care medicine is clearly a “horizontal” specialty, one that cuts across the traditional “vertical” boundaries of established specialties. Therefore, critical care medicine ranks with an increasing number of synthesizing activities in medicine, such as oncology, infectious diseases, clinical pharmacology, and clinical epidemiology. There is no longer any doubt that critical care represents a clearly definable body of knowledge and competency that frequently relates to a rather stereotyped final common clinical pathway of multisystem organ failure. For example, it matters little to the clinician or the lung whether the respiratory system has been “hammered” by a bus, a virus, or pus in the belly—the common presentation of respiratory failure, with its attendant need for life supportive measures, is remarkably similar in all three circumstances. It, therefore, seems a disservice to the patient, and certainly to the profession, to suggest that only an internist (or chest physician) can understand the phenomena of multisystem organ failure in a “medical ICU,” or that only a surgeon can fathom the same clinical complexities in a “surgical ICU.”

重症医学显然是“横向”学科,与已存在的传统“纵向”专科不同。因此,重症医学与医学领域中逐渐增多的交叉型专业,诸如肿瘤学,传染病,临床药理学和临床流行病学等一样。毫无疑问,重症医学对不同病因导致的多器官功能衰竭,具备明确的知识和救治体系。例如,临床医师或胸科医师很少关注,呼吸系统由何种“打击“(公共汽车,病毒或腹腔感染),造成呼吸衰竭,及需求生命支持措施的辅助,因为这在三种情况非常相似。因此,建议只有内科医师(或胸科医师)能够理解“内科ICU”中多器官衰竭的现象,或者只有外科医师能够了解在“外科ICU”中的相同的临床复杂性,这似乎对病人乃至整个行业都是不利的。

Nature abounds with examples of territorial behavior, most apparently designed to preserve prerogatives in association with mating, food gathering, or in boundary and group identity maintenance. Mankind has not been immune to this sort of behavior, perhaps best illustrated by the Guild systems of the Middle Ages from which the professions and specialties are derived. The development of no fewer than four Boards (are there more to come?) for Critical Care in the United States must be viewed as having territorial and Guild system overtones, designed, at least in part, primarily to benefit the Guilds membership. It is unquestionable that each of the traditional “vertical” specialties has a legitimate concern with the problems surrounding the evaluation and subsequent management of multisystem failure. What is less clear, however, is the wisdom of, or the need for, each traditional specialty offering its own educational processes leading to separate certifying examinations. In order to avoid the inevitable fragmentation of patient care, the development of biased training programs in critical care (conceivably with the multiple Boards, there could be several critical care training programs in the same institution!), and a proliferation of specialty-based intensive care facilities in hospitals, it would seem to us that the more sensible route would be to embody the development of a cooperative, multidisciplinary approach to patients who are seriously ill.

大自然中有许多领地争夺的事例,主旨是为了维护交配,食物采集等特权或保持领地边界和群体身份认同。人类也不例外,中世纪,职业和专业从行会体系中派生的过程可能是最好的证明。在美国,重症医学领域至少有四个学会(还能更多吗?),这样的发展模式带有有领地和行会制度的基调,至少部分目的是为了使行会成员受益。毫无疑问,每个传统的“纵向”专业都对多器官功能衰竭的评估和后续管理方面的问题有着合理的关注。然而,尚不清楚的是,由每个传统专业提供的特有教育流程,主导相对独立的认证考试,是否明智或必要。为了避免患者救治的片面性,针对重症医学中带偏见的培训计划的发展((考虑到存在多个专委会,同一机构可能有多个重症医学培训计划),以及医院中以专科为基础的重症监护设施的增多,在我们看来,更明智的做法是体现针对重病患者的多学科合作。

In Canada, the Canadian Critical Care Society (CCCS) and the Royal College of Physicians and Surgeons (RCPS) have gone a different route. Quite frankly, they have found the territoriality and fragmentation occurring in the United States a positive stimulus toward encouraging consensus around the creation of a critical care training program. In September of 1986, the Royal College, the official body responsible for accreditation of specialty training programs and certification of specialists in Canada, gave formal recognition to critical care medicine and thereby created a Specialty Training Committee which was charged with the task of overseeing an experiment known as “Accreditation without Certification”—a process that primarily focuses on the educational aspects of training programs. This program is based upon an Educational Objectives document that was written over a two-year period by the Canadian Critical Care Society and the Royal College Advisory Committee on Critical Care. The development of this document involved all the specialties concerned with critical care issues. The Educational Objectives document was specifically designed to describe the care that trainees would be expected to provide during independent practice in critical care. Thus, it identified specific terminal and enabling objectives. Career stream specialty training in critical care in Canada now requires the successful completion of training and certification in any one of the traditional primary specialties, with the addition of two further years of critical care in a Royal College accredited, university-based program. One of the two critical care years may be taken within the four- to five-year primary specialty-training program; specific elements of prior training relating to critical care may be recognized by program directors as fulfilling no more than one year in the two-year Critical Care Training Program. Training, within accredited critical care programs, and based upon the Educational Objectives document, may also be designed according to specific career goals of the trainee. It is nonetheless understood that there exists a commonality of fulfilling objectives for all candidates regardless of their primary discipline. This process of training will not be difficult, as many critical care units in Canada are of a “multidisciplinary” nature.

在加拿大,加拿大重症监护学会(CCCS)和皇家内外科医师学院(RCPS)走了一条不同的道路。坦率地说,他们发现美国发生的地域性和分割化现象对重症医学培训计划达成共识具有积极的促进作用。1986年9月,加拿大皇家学院,负责认证加拿大专业培训计划和专家认证的官方机构,正式认可重症医学,并由此成立了专业培训委员会,尝试负责监督称为“无证书认证”的计划,其主要侧重于培训计划的教育方面。该计划基于加拿大重症监护学会和皇家学院重症监护咨询委员会在两年内编写的《教育目标》文件。文件涉及与重症医学问题相关的所有专业。“教育目标”文件明确描述了受训者在独立重症医学实践中,应该可以提供的治疗(方法)。因此,它确定了特定的终点和可行的目标。加拿大的重症医学专业培训流程,需要完成任何传统基础专业的培训和认证,在此基础上,还要在皇家学院认可的大学附属医院完成两年重症医学专业培训。两年中的一年,可以在四到五年的初级专业培训计划中完成。项目主管可能会认可之前与重症监护相关的特殊培训,作为两年重症医学培训计划中的不超过一年的一部分。在认证的重症医学计划内并根据“教育目标”文件进行的培训,也可以根据受训者的特定职业目标进行设计。尽管如此,可以理解的是,对所有受训者来说,无论其主要学科是什么,实现的目标都存在共性。由于加拿大的许多重症监护室具有“多学科”属性,因此培训过程并不困难。

It must be emphasized that the experiment of creating the Accredition without Certification Program, and the prerequisite of producing the associated Education Objectives document, was a multidisciplinary effort involving coordinated input from anesthesia, surgery, medicine, pediatrics and the Canadian Critical Care Society. This process required extensive discussion in order to establish consensus, not only regionally across the country, but also between vested specialty interests. It seems likely that the harmonious development of this multidisciplinary approach was assisted by the unitary control exerted over the credentialling, accrediting, certifying and examining training components by the Royal College. The Canadian National Health revenue, characterized by: (1) universal patient access, (2) global-budgeting for hospitals, (3) and a single source third-party reimbursement system, also may have been contributing factors. With agreement and understanding of all disciplines represented by the Royal College of Physicians and Surgeons, critical care training in Canada will combine and utilize the talents of anesthetists, surgeons, pediatricians and internists in the multidisciplinary, life-support environment.

必须强调的是创建无证书资格认证计划的尝试,以及制定“教育目标”相关文件的前提条件,是麻醉,外科医学,儿科和加拿大重症医学协会等多学科之间相互协调,共同努力。为了在全国范围内和专业协会既得的利益之间建立共识,这一过程需要广泛的讨论。皇家学院对培训,鉴定,认证和检查培训内容的统一控制似乎有助于这种多学科方法和谐发展。加拿大国民健康财政收入(其特点是:①广泛的病人来源;②为医院制定整体预算;③单一来源的第三方报销系统),也可能是促成因素。在皇家内外科医师学院代表的所有学科的共识和理解下,加拿大的重症医学培训将集合并充分利用麻醉,外科,儿科和其它来自不同学科及生命支持领域的优秀医生。

We genuinely feel that this cooperative approach will best serve the seriously ill patients for whom we care, as well as the profession. At a time when most primary disciplines have fragmented into numerous subspecialties and superspecialties in the 1970s and 1980s, it is imperative that the growth of formalized critical care training in Canada emphasize a multidisciplinary and comprehensive approach to training in the care of the seriously ill patient. Having put a colossal amount of work into developing this collegial attitude, we feel its virtues justify our advocacy of the multidisciplinary approach not only to education, but also to care provision and research expressed in this editorial.

我们真诚地认为,这种合作方式将最好地服务于我们所救治的重症患者以及有利于整个专业。在1970年代和1980年代,大多数主要学科都细分为众多的亚专业和超亚专业时,加拿大正规的重症医学培训的成长势在必行,它强调了针对重症患者救治的多学科,综合的培训方法。通过投入大量的工作,来发展这们综合学科的态度,我们觉得它的优点证明了我们倡导的多学科方法不仅适用于教育,而且适用于本述评中提到的(临床)救治和(科学)研究。

Perhaps it is not too late for American critical care constituents to reawaken earlier ambitions for multidisciplinary cooperation in the development of critical care training programs. Territoriality maybe fine for the insect, bird and animal world, but it is bound to deprive patients and trainees of points of view that are important for their welfare. If our two countries continue along their disparate paths, it may be ultimately possible to compare the merits of the two systems. In the meanwhile, as neighbors, we ask that if you must have territorial disputes, please keep the ruckus down so that property values do not fall in the entire neighborhood.

对于美国重症医学从业者来说,重新唤起早期在制定重症医学培训计划方面进行多学科合作的雄心还不算太晚。对于昆虫,鸟类和动物界来说,地域性可能会很好,但是(对于重症医学来说)势必会剥夺患者和受训者对于自身的权益。如果我们两国继续沿着各自不同的道路前进,那么最终有可能比较这两个系统的优势。同时,作为邻居,我们希望,如果你们必须有“地域”争端,请保持克制,以免对周围邻居产生不利影响。

(翻译:周飞虎)

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