Wednesday, February 03, 2010

Who is an Intensivist?

Dear all....Recently I started this thread on the yahoo groups website

criticalcare_interactive@yahoogroups.com ....Who is an Intensivist?


Dear Fellow Intensivists

I have been in the United States for close to 5 months now and Critical Care Medicine is a different picture from what it is in our part of the world.

It is not a new fact that Critical Care or Intensive Care , as it is called in the Indian subcontinent has largely been taken over by a core anesthesiology group. This is based on a pattern seen in European countries and Australia. However in the United States it is still a very split domain between pulmonologists,surgeons,
physicians and anesthesiologists.

The good thing though is that most big centers have been able to come up with fellowships in "Anesthesia and Critical Care Medicine" which are tailored to training Anesthesia residents.

Where are we in India in terms of an integrated DM in "Anesthesia and Critical Care". Why is it that the only DM program is one in "Pulmonary and Critical Care" which does not permit an MD Anesthesia to qualify to take that exam.

I see Intensive Care as an integral part of Anesthesia ,though my honorable colleagues in other specialties may say that I'm biased. In fact it is time that the anesthesia fraternity put there hand up and take charge of there rightful place in the ICU.

Please give your inputs.

Ashish K Khanna M.D


This is an issue I personally feel very strongly about....I believe Critical care is an independent speciality in itself and should be ready to welcome all areas of background training...i.e Anesthesia,Medicine,Surgery,Pediatrics and Pulmonology...This is sadly lacking in India where the emphasis is on DM programs such as Pulmonary Critical care ...Pediatric Critical Care etc...

Here are some valued opinions of the experts in this field:

Dear Dr. Ashish
what I feel that intensive care should not confined to one group of specialist, so any one who is having keen interest in critical care can do it weather he is a pulmonologist or anaesthetist, but only condition is that one should do it whole hearted and on full time basis, as everyone will agree that no body can sail in two boats simultaneously and if some one says that he can do it, probably he is a superhuman. one cant do to both the specialities be it pulmonology or anaesthesia and intensive care. Intensive care is a very demanding branch and needs full time (most of time over time) dedication, only than one can do justice with patients, if some one feels that by taking rounds for 15mts in ICU and rest of time doing work with parent branch can become Intensivist he is be fooling himself
Dr. Deepak Govil
New Delhi




Dear All,
Just my perspective:
Critical Care is a hybrid Speciality and I have worked and qualified from Australia (am now in CMC, Vellore) from the Physician's stream. In Australia, both Anaesthetists and Physicians had separate streams for training which was unified as the Joint Faculty of Intensive Care and is now the College of Intensive Care from 2010.
I strongly believe that Anaesthetists, Pulmonologists, Internists and Paediatricians are all equally "qualified" to be Intensivists provided they go through a period of training which gives adequate training in all domains of Critical Care. I have worked with both physician and anaesthesia trainees during my training and both are strong in some domains but need additional input in others. Physicians are apt to be "meditative" in dealing with problems which need immediate intervention while anaesthetists go straight into action! Physicians also need to polish their skills in intubation, CVC insertion etc.
Anaesthetist trainees on the other hand seem to get restless when their patients are on long term ventilation - they are used to waking them up post op! In addition, antibiotic therapy, nutrition and counselling are skills they need to acquire which the physician trainees already have in a greater measure.
In this scenario, the Medical Council of India has not yet recognised Critical Care as a distinct speciaility - inspite of concerted efforts by several prominent doctors. We (CMC) have prepared a DM syllabus with entry qualification for MD Internal Medicine, Pulmonology, Anesthesiology, Paediatrics and given it to the University but the MCI has to wake up before anything can happen. The present DM in Pulmonology and Critical Care, is in my opinion, short sighted as it resticts it to just Pulmonologists and several domains (the most obvious being the whole field of Trauma) is ignored.
The course of IDCCM and IFCCM by ISCCM is more aligned and on track with the ideal training for an Intensivist
In summary,
A good intensivist must have
The keen observation of a paeditrician (as the patients cannot talk),
The patience of an obstetrician (watchful waiting is part of beneficial therapy),
The thoughtfulness of a physician (multiple complex problems need sorting),
The rapid reflexes of an anaesthetist (quick thinking and action as needed),
The aggressiveness of a surgeon (definitive invasive intervention when needed),
The communication skills of a psychiatrist (families and friends need counseling),

And most essentially,

The diplomatic skills of a UN Secretary General
(interaction with multiple specialties each with their own agendae)

Regards,

Dr. George John MD FRACP FJFICM FCICM

CMC Vellore



In my view, there is no reasons why anyone trained in acute medicine (and anaesthesia is ACUTE MEDICINE!) cannot train to do intensive care. All one needs is motivation, training and then the will to work in critical care. My unit (with 14 consultants or permanent intensivists) has a preponderance of intensivists whose base speciality is anaesthesia (12)! Only one is physician (pulmonologists) and the other is an emergency physician. This is the general pattern in the UK.

But we are now training more and more physicians and emergency physicians in intensive care medicine and long may it continue! Poor surgeons – still don’t want to mess with the patients and their problems!

Cheers.

Roop Kishen,



Dear All,

I am of the opinion Intensive care should be led by pure intensivists
(who could be a pulmonologists,surgeons,physicians or anesthesiologists)

From what I have seen and learnt in UK , Any chimp can be trained,
any one from any specialty can be trained, provided is committed and capable of delivering the goods.

India has more confidence in the individual merits of a learner than in the Medical teaching/training programmes,
India has compartmentalised education for long, It is time to break free.
If we have a wholesome training programme in which we have confidence then we should be able to make an intensivist out of almost anyone, who has a passion and commitment.

I believe we are the same people who love the idea of walking into a car shop and buying a car of our choice in modern India, rather than be forced to buy a Ambassador as in the past.

To have the opportunity to chase your passion is important, & to provide that choice is important.

Why should we have a DM in critical care in India? Why were anaesthetists excluded? Why should it be a limited club?
We are already so good at creating heirarchy and monopoly, it's time we introspect.
We need to separate academics from practice.
Do we just want to create limited number of people who can talk hours of academics, rather than people who can get on and deliver critical care.

What is the national need for critical care? any numbers?
What is the scope of growth for critical care in India?
What is the number of trainees/practitioners needed?
How are we going to meet the needs?
What is the expectations of the knowledge skills attitude and behaviour from such a candidate?
Can we meet it through a well defined single national programme which meets international standards like the EDIC ?
Will we have the confidence to handover our relative who is critically ill to some one who has been trained through such a programme? (the acid test)

Well before all that, Is there a consensus on which Resuscitation guideline we follow as a nation ?


http://anaesthesia-intensivecare.blogspot.com

Dr Sam George
MD FCARCSI
UK


Dear All

I am a consultant anaesthetist working in th Uk for the pat 15 years of which I have been a consultant for 10. I have worked as an intensivist as well for 6 yrs on a very gruelling rota of 1 week in four on the ICU.

As Sam has said ICU or critical care is a speciality in its own right and that has been well recognised and is treated as such especially in Australia. No particular speciality should have an ownership to it. Here in the UK that is now being addressed with dual accreditation where in you have a core speciality and then you also get admitted to a critical care training programme thru compettition and come out at the end of it as a dually trained individual. however we havent moved to a full time intensivist only led ICUs` yet. There are a lot many reasons for it. In my mind as I am sure most of you would agree with me - Critical care should be Ideally delivered by full time intensivists whether this is possible and practical is another matter.

Critical Care needs a particular set of knowledge and skills and if a programme can develop and deliver that then you have an intensivist at the end of it.

As an anaesthetist we do have a lot of skills that are required everyday on the icu so it should follow that we as a speciality that cannot be excluded - however the knowledge required is a different ball game which then needs to be addressed.

Talking about INDIA we have a great many institutions with enough and more clinical material. There is no reason why we cannot create a speciality if we put our minds to it. Bodies such as Indian society of critical care medicine should be able provide leadership for it.

Having said all of this - we have to get back to basics which is REGULATION. We need a very strong National Medical Council which will drive the EDUCATIONAL and ETHICAL practice of Medicine in our country. Without this we will continue to swim in the quagmire we are in.


Regards
Dr Poopulli Ravindran ( Ravi ) MD FRCA



Hello everybody!

It looks like we intensivists have an identity crisis! There is a serious dearth of qualified intensivists in our country. At the same time, it is good to see that it is rapidly growing. The swine flu pandemic I think has done some good to our specialty. It sure has made people realise the importance of the specialty.

As many of the colleagues have opined, nobody should claim that the specialty belongs to them. I only dream of a day when the subspecialties walls of intensive care are broken down (surgical ICU, Medical ICU. Neuro ICU etc) and we function as a unified single unit in India. Worse, there are many places where the cardiologist, pulmonologist, nephrologist etc take care of the respective systems and I always wonder how the wiring between them will take care of a patient. We need a closed ICU system. A single closed ICU would enable the faculty to improve in academics and cinical skills so that the Anaesthesia based intensivist will wait patiently when necessary and the Medicine based intensivist will have the quick reflex when necessary (as Dr. George John puts it)!

As a specialty if we work for the recognition, I am sure the MCI would listen. I had a long discussion with an official in the MCI a couple of months ago, who was favourable for this idea. Has anybody in this forum been in touch with MCI or their respective universities (I know that Dr. George John worked on this with Dr. MGR medical University) for such recognition? Let us make it happen.

PS. Has your own institution recognised you as an intensivist? I was called "you are only an Anaesthetist" some 7 years ago in Vellore. Now they will not dare to repeat it!

Regards
Subramani


Dr. K. Subramani M.D., D.A., FRCA. EDIC.
Associate Professor
Consultant in Anaesthesia and Intensive Care
Christian Medical College Hospital
Vellore - 632004
Tamilnadu
India

7 comments:

  1. DEAR FRIENDS I AM ASSISSTANT PROFESSOR IN EMERGENCY MEDICINE BUT ALSO LOOK AFTER THE ICU SO CRITICAL CARE IS NOT ONLY FOR YOU. (WE) THE EMERGENCY PHYSICIANS ALSO COMING UP WITH ICU SKILLS.MD A&E ALSO ELIGIBLE PEOPLE TO DO CRITICAL CARE MEDICINE COURSE AS PER EUROPEAN DIPLOMA IN CRITICAL CARE MEDICINE WHY NOT ICCM NOT CONSIDERING US,BUT THEY ARE INCLUDED DIPLOMA IN OTHOPEDIC AS AN ELIGIBLE CRITERIA TO DO INDIAN DIP IN CCM.YOU KNOW IN SRILANKA WITH MBBS,ANY DOCTOR CAN DO DIP IN CRITICAL CARE MEDICINE WHICH IS RECOGNIZED BY SRILANKAN MEDICAL COUNCIL.ALSO MOST OF ICU PROCEDURES MBBS DOCTOR CAN DO AS PER MCI INTERN TRAINING RECOMMANDATION(PLZ VISIT MCI WEB SITE) INCLUDING MONITORING,INDIAN POPULATION IS BIG NEED FOR INTENSIVIST ALSO HIGH SO PLEASE BRING THE ICU MEDICINE UP TO PHC"S.THANK YOU

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  2. i am in still to worry anaestheasian people not taken part dm critical care in pgimer what made diffrence in uk ,us, and india

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  3. The debate is never going to end.But due to some reasons or other anesthesiologist are getting less and less involved in critical care.It is high time that the anesthesis fraternity gets sensitised on the issue and takes charge.We the anesthesiologist have the practice in our blood.Only anesthesia training incorporates on all critical care skills.The training should probably be restructured to be in sync with modern intensive care.
    Wake up call...........
    Dr Yash Javeri
    Dr Yash Javeri

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  4. Critical care is a speciality on its own.A D.M course with entry open to chest physicians,anaesthetists emergency physicians etc.etc. is the way to go.However the MD anaesthetic curriculum in India needs to incorporate training time in critical care,medicine,chest diseases and emergency medicine.I feel that it is impossible to do that in 3 years.
    Anaesthetists think in series one problem at a time while critical care needs doctors to think in parellel.
    Finally there is a role for a part-time intensivist.The day time decision making should be undertaken by a critical care physician while the on call roster can be managed by the part-timers.
    Manesh FRCA FANZCA

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  5. Dear Dr.Manesh
    I fully agree with you sir.But Indian MD/DNB Anaesthesia has sufficient stuff to manage a critical care situation and we are doing it ok ( If not up to UK/NZ standards).Anaesthesiologist turned Intensivist thinks in series of the situation and a non Anaesthesiologist intensivist thinks only Medical problems!!!
    Nambiar Nag

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  6. Dear Mani,
    Frankly It is not OK,Our exams need to be standardised then only I will believe that a candidate will deliver the minimum expected standards (DNB critical care may, MD is often not upto standard and the quality variation between Universities are like -50 to + 50).
    A strong Medical Council,A dynamic Academy of Anaesthesia/critical care,which ensures professional regulation,ethics and CPD, Uniformity in practise as per the latest evidence,these are the minimum requirements,

    I have been to few ITU's in India, they talk entirely different things,depends entirely on who is leading it.

    There is no magic in UK/NZ standards India could do it even better if we have a collective will,a constructive outlook,shun personal and regional egos, ensure team approach and stop being lazy to maintain standards, Let us stop being followers for ever and start taking responsibility.(Look at the number of deaths Japanese encephalitis has caused what was the response from Doctors bodies, or any medical fraternity, I did not even hear a compassionate statement.)

    In UK they all follow things ritualistically like the Army and are disciplined they lay down the foundations well,
    (to quote an example,Look at the planning of Chandigarh or New Delhi and look at their state now.)
    Individually each leading practitioner in India comes out as 'Brilliant' quoting literature and so on, but as a society/fraternity they often fall flat,that is because the brilliant people are not the leaders,It is often some short sighted ........,we need introspection otherwise we will miss the boat for ever.

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  7. dr Sharma Shrinivas.MD,FICM,PGDHHM,PGDMLS.
    I personlly feel pity on indian medical education and rather say the post graduate training programmes.
    we say,we have adopted UK system but its a complete different scenario out there in UK and india.why i am saying this is because,indian doctors after graduation are bombarded with thousands of pg entrance exams anf forced to take the seats according to ranks and not according to there interest.in outcaom they dont give desired results.
    2nd thing-in UK when doctor has done his MBBCH,for pg he has to search jobs of his interest and at the end of residency appear for exams of royal college.in india district hospitals are run by interns and BAMS,BHMS doctors and there are no pg seats in these government hospitals.why cant we train physicians and specialists in these hospitals?
    more over....why reservations for pg.i mean reservation on the basis of caste?does the disease discriminates on basis on caste,if not then by doctors??

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