Standards for Education and Credentialing in Critical Care Medicine

Abstract

HE PROVISION OF INTENSIVE CARE TO PATIENTS IN THE throes of life-threatening acute illness is one of the most important and most expensive parts of US health care. Today, adults in the United States are increasingly likely to receive intensive care unit (ICU) care compared with previous generations, with the greatest ICU resource use occurring among older patients and those at the end of life. 1 Several million individuals are admitted to ICUs in the United States each year at a cost approaching 1% of the nation’s gross domestic product. 2,3 A large body of evidence suggests that the likelihood a patient will survive an episode of critical illness is exquisitely dependent on how the ICU is staffed. 4 In particular, care led by physicianstrainedandcertifiedincriticalcaremedicine(CCM) isstronglyassociatedwithimprovedoddsofsurvival.Inthe rest of the developed world, ICUs are staffed exclusively by physicians trained in CCM. However, in the United States, only a third of patients in the ICU are managed by critical care physicians. 5 There is no coordinated effort to train an expanded workforce of CCM physicians. In the United States, CCM is recognized neither as an independent discipline such as surgery, internal medicine, or anesthesiology, nor as a conjoined subspecialty with uniform education, training, and credentialing. Rather, there are now 6 separate adult intensive care training pathways following residency training in anesthesiology, emergency medicine, internal medicine (either as critical care alone or jointly with training in pulmonary medicine), neurology, and surgery, leading to an array of training programs with separate credentialing criteria. No other medical subspecialty has such an inconsistent approach. Criticalcaremedicineseemstobemovingawayfromuniformstandardsevenasitmaturesasaspecialty.Criticalcare medicine arose in the United States during the 1960s just as ICUs emerged. In the United States, CCM has been regarded as a “niche” specialty in that training is undertaken by a minority of physicians within a primary specialty. 6 In