[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.
E. Garner King和William Sibhald医生是国际公认的重症医学专家。他们在本期题为“ 地域法则”的特邀述评中，对于我们美国重症医学进行的正式培训和亚专业认证方式，表达了加拿大同行体贴的，深思熟虑的关注。他们认为，内科学、普通外科、麻醉学和儿科专家之间的培训和认证过程的分离，违背了能更好地为患者提供最佳救治的更合理的多学科手段。他们确定重症医学是具有适当知识体系的合法学科；它与传统的 “垂直”的基于器官的专业不同之处在于它是“水平”的，从某种意义上说它关注危害生命和多器官损伤。因此，顾名思义，重症患者的救治是多学科共同的任务。
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.
这些加拿大领导人既谈到组织，也谈到教育过程，这有助于优化由专家主导的重症监护治疗。他们很不情愿地得出结论，他们发现的地域主义毫无帮助而且违背基本的多学科原则。为什么，他们问：重症医学有四个基本独立的专业委员会并且可能还会增加？为什么对重症医学专科医师进行的培训和认证过程包括考试，对每门专业来说是独立和独特的？他们得出的结论是，这主要是经济驱动的，或者如他们所说，是中世纪行会制度的保留。他们指出，这是一个旨在保持领域特权的制度，并暗示其专业竞争的经济利益。虽然这两位领导者都是高素质的胸科医师，但他们承认其他亚专科医生可能也可以胜任重症救治的工作。他们认为可以在内科，外科或其他专科重症监护室中提供此类救治。实际上，他们坚持这样的观念，即包括麻醉师和儿科医生在内的内科和外科专家都可以接受培训并且能够提供此类服务。
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.
我们的加拿大同行所采取的谨慎态度没有什么错。当然，加拿大皇家内外科医学院所采用的更为普遍的选择也没有什么错。此外，重症医学学会传统上也赞成这种多学科方案。现在，重症医学由四个独立的委员会分别认证的现状是一种务实但非最佳的解决方案。它反映了在专家和专科医师之间，尤其是在胸科医师之间的不同观点，这些胸科医师在独立组成的专业委员会的决策中起代表作用。
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.
从事重症医学的人可能会认同，重症患者即病情危重，累积一个以上或多器官系统，应由具有多学科重症监护技能并且能持续在重病或重伤患者床旁看护的医生进行救治。然而，在单器官功能衰竭终末期的患者中（例如长期冠状动脉疾病后的慢性充血性心力衰竭，慢性阻塞性肺疾病患者的终末呼吸衰竭或癌变的术后处理），对于未经过重症监护培训的基于器官的专家来说，可能还有一席之地。但是，这可能是少数患者。毫无疑问，当专家的意见或程序化的干预措施适当时，“垂直”的专科医师的特殊知识和技能应有助于危重患者的受益。
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.
我们加拿大的同行们以值得赞赏的方式解决了这些领域问题。这已经超出了他们所说的割裂化的领域范围，这也是我们国家统一培训和认证过程的障碍。加拿大人强调培训和服务的共性，从而避免了学科分割化的情况，这有利于合作的、学院的多学科培训计划和不受亚专业限制的实践安排。
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.
目前，木已成舟，美国的认证模式正在以预定的方式进行。也许我们缺乏“所罗门式”的智慧以阻止我们过细的分割（学科）。我们还需要向北方邻居学习很多东西。尽管如此，正如我们之前指出的事实，现有专业学会，涉及重症医学的其他专业学会以及重症医学协会之间的合作非常好。我们应该注意加拿大邻居传达给我们的温和而有效的信息。因此，我们将努力地促进合作，首先要从目前负责重症医学专科医师认证的委员会之间进行联合审查开始。我们还希望确保由一个专委会认证的重症专科医师，如果具有足够的经验和技能，在为其他学科服务时不会受到约束。
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.
最后，见证了重症医学孕育和出生的我们这些人，对重症医学已经成熟这一事实感到非常自豪。我们已经达到可以在认证过程中建立对话的水平，这一事实体现了压倒一切的好处。现在，我们着眼于美国重症医学事业持续发展，使其越来越融合发展，发挥与传统的专业和亚专业并驾齐驱的多学科优势。
（翻译：周飞虎）
