The Future Intensivist: A response
by John Gannon
I remember the ‘critical care’ silo mentality that Dr Gary Masterson refers to. However, the problems created by so called ‘single organ doctors’, at that time, where not caused by the ‘ologists’ referred to, but by the ‘anaesthesia based intensivists’ who created the ‘silo’ mentality by shrouding critical care in the complexities of organ support. They did this by jealously guarding the critical care patch and dismissing any attempt by the ‘meddling ologists’ to get involved!
I share the views of many who have suggested that critical care medicine should be viewed as the primary specialty
Let’s not forget that many UK intensivists entered anaesthesia training after one year as a house officer and thus have little experience of the broader aspects of general internal medicine. Whilst accepting the pivotal role of anaesthesia in the genesis of UK critical care we must also now accept that the ‘holistic’ intensivist is more likely to come from a background of general internal medicine training. Indeed, I share the views of many who have suggested that critical care medicine should be viewed as the primary specialty rather than some form of ‘bolt-on’ addition.
All too often I see enthusiastic Foundation trainees who are given the impression that the only route to critical care is through anaesthesia training, with an over emphasis on the need for advanced airway skills as the main factor.
A good anaesthetist does not necessarily make a good intensivist. Similarly, anaesthesia based intensivists are not necessarily the best at delivering safe anaesthesia care to sick or challenging patients!
I look back on my critical care experience and express a debt of gratitude to all the ‘single organ doctors’ who knocked on my door asking for help. They made me reflect on difficult decisions relating to admission and discharge and especially in consideration of end of life issues.
The widespread practice of ‘demand elasticity’, in terms of bed management, sends conflicting and confusing signals to our medical and surgical colleagues
There is an inconsistency in many UK ICUs in terms of admission, discharge, and EOL care. The widespread practice of ‘demand elasticity’, in terms of bed management, sends conflicting and confusing signals to our medical and surgical colleagues. Coupled with the historical inappropriate pessimistic attitude to certain disease groups, it does beg the question as to whether UK critical care is the last bastion of medical paternalism.
Critical care outreach should not be confused with a MERT. There is overlap but ownership of the MERT should rest within the broader acute hospital structure whilst the CCOT should remain as a focus of contact between critical care referrals and discharges.
Perhaps the greatest challenge facing UK critical care resides with the burgeoning demands of level 2 and 1+ care. This is a problem of our own making with over expansive aspirations to control all level 2 activity, the latter enshrined in the bible of GPICS!
We need to have a sensible debate about level 2 and 1+ care, accepting that other models of care are sustainable such as the concept of EPOC (enhanced postoperative care) delivered from a shared surgical, anaesthesia platform with critical care input. Our colleagues in respiratory medicine have relieved us from an enormous burden with the establishment of non-invasive ventilation units. Renal medicine already provides invasive organ support to an ambulatory population and acute cardiac units should be encouraged to rediscover the art of inotropic support and modes of non-invasive oxygen therapy.