Critical Care Medicine

Abstract

Critical care medicine (CCM) as a viable subspecialty of anesthesiology is approaching a crucial period in its existence that will determine whether it can survive as an important component of our specialty or be relegated to our medical, surgical, and pediatric colleagues. With the many changes in health care delivery, the future survival of anesthesiology as a specialty may well depend on the acceptance that perioperative involvement, rather than sole intraoperative anesthesia practice, is the purview of the anesthesiologist. No longer are economic incentives and desirable time management positive factors to induce young physicians to consider anesthesia. Workloads are increasing, economic return is decreasing, and jobs are less plentiful. Yet, the opportunity to care for increasingly complex patients with more sophisticated monitoring and therapeutic modalities, applying scientific physiologic and pharmacologic principles that are the basic tenants of medical practice, still makes anesthesiology an exciting and desirable profession. A crucial part of our role as perioperative physicians is our involvement in postoperative care of the critically ill surgical patient. To allow this role to disappear would not only diminish our contribution to patient care but also our value and ability to attract high-quality medical students. CCM became a recognized subspecialty of anesthesiology in 1986, with the first issuance of certificates of special qualifications by the American Board of Anesthesiology (ABA). The number of anesthesia critical care medicine (ACCM) physicians remains exceedingly small. To date, there are 622 certified ACCM specialists compared to 4737 in medicine and 1334 in surgery. It is anticipated that approximately 140 anesthesiologists will attempt the biannual CCM examination in 1995. This compares to 4500 candidates for ABA primary certification for the past two years. Stoltzfus et al. in the current issue of Anesthesia & Analgesia have reported the results of a survey of accredited ACCM programs investigating the numbers of faculty and trainees as well as their practice patterns for the 1992-1993 academic year [1]. They received completed questionnaires from 36 of the 42 programs existing at that time. Twelve of the 36 programs had no ACCM fellows. ABA data compiled from training reports required of ACCM programs summarize the number of anesthesia trainees over the past five years as reported on June 30 of that year. This is shown in Table 1. Stoltzfus et al. also report the scant number of applicants to the 36 programs they surveyed, with 1 receiving no applicants, 14 receiving 1-2, 5 programs receiving 5-6 applicants, and 7 programs more than 6 applicants.Table 1: American Board of Anesthesiology Critical Care Medicine Training Report Information for Anesthesia TraineesThese data indicate justifiable concern. It is therefore necessary to investigate factors influencing this apparent lack of enthusiasm among our graduating housestaff for further training in CCM and to identify opportunities to increase involvement. A major, if not the most important, factor is the relative support and enthusiasm of academic anesthesia chairpersons for the involvement of their departments in the intensive care units (ICUs). Without their desire and effort to secure this involvement by aggressively promoting the efforts of anesthesia in the ICU and by gaining the support of their medical, surgical, and pediatric colleagues, there is little reason for optimism. Hospital administrators must also be convinced that the continuous presence of identifiable CCM physicians can positively affect outcome. Improved care accompanied by reduced length of stay, and thus cost, in the ICU must be demonstrated to justify our existence. Knaus et al. [2] and Zimmerman et al. [3] have published studies indicating the positive impact of CCM specialist presence and direction in the ICU. The necessity for increased involvement of anesthesiologists in academic CCM to attract future trainees is intuitive. Durbin and McLafferty [4] identified factors influencing anesthesia resident interest in CCM to include the administrative role of the anesthesia department in the ICU and the level of responsibility of the anesthesia resident for patient care. Despite the above concerns, there are reasons to hope for increased interest and opportunities for anesthesiologists in CCM. Increasing competition for available jobs will reward those with advanced training. CCM training is not only beneficial for the provision of intensive care in the ICU, but should increase the intraoperative ability and expertise of the anesthesiologist through the skills attained during ACCM training. The perceived disparity in time-related income achieved between operative anesthesia and ICU management will likely diminish and that, accompanied by a desire to maintain quantity of work, may induce more involvement of the anesthesiologist in community ICU care. Stoltzfus et al. end their article by indicating the belief shared by 19% of the 36 program directors that the CCM fellowship in anesthesia "should be lengthened beyond 12 months" [1]. What is the goal? If the fellowship is preparing trainees for academic careers, provision of research training and experience warrants added time. Clinical training, however, added to three years of anesthesia training that includes two months of CCM as well as constant experience with critical care in the operating room, should, in my opinion, be sufficient if provided in a well structured 12-month fellowship. Requiring additional training for all CCM fellows would likely reduce the number of clinically motivated applicants, who are already burdened with large financial indebtedness and impatient to seek job opportunities and begin practice. Board certification and issuance of qualifications for subspecialization should not be predicated on achievement of academic potential but rather clinical expertise. Bacon and Lema [5] in their historical review of ABA certification refer to the first written examination in anesthesiology on March 28, 1939, as "a pivotal day for the specialty of anesthesia" in providing to anesthesia physicians "the opportunity to be considered specialists." We are likely approaching another pivotal period in our specialty, one that requires the continued provision of the best operative care available with increasing involvement in perioperative medicine. CCM is a crucial component of this practice philosophy, and every effort to increase our involvement and attract future specialists must be a prominent focus for the immediate future.

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