From the Chair - Peter’s Laws and the Future of Training in EM-CCM
Critical Care Medicine Section
April 2010 - Vol 11, #2
Lillian L. Emlet, MD, MS
Assistant Professor, Critical Care Medicine
Program Director, EM-CCM Fellowship of the MCCTP
University of Pittsburgh Medical Center
Pittsburgh, PA
No. 2: When given a choice—take both!
I never had the honor to meet the late, great Dr. Peter Safar, from whom CPR and the belief that resuscitative critical care of the patient began with the basics: ABCs. Peter continues to be known here by his “Peter’s Laws for the Navigation of Life.” Here, in Pittsburgh, one hopes that the legacy of Peter Safar continues not only with research in “resuscitation medicine” but also with education and training in critical care medicine. Peter Safar started the first intensive care training program in 1964, and also the first ambulance company in Pittsburgh in 1967, the Freedom House Ambulance Service.6-7 The roots of EM-CCM began with Peter, who believed that resuscitation began anywhere that emergent and critical care was needed, not limited by geography or territory.
“We consider CCM to be the triad of 1) resuscitation; 2) emergency care for life threatening conditions; 3) intensive care, ie, those aspects of service, teaching, and inquiry anywhere in the emergency and critical care medicine (ECCM) system.”1
“The CCM physician is a specialist in Anesthesiology, Emergency Medicine, Internal Medicine, Pediatrics, or Surgery, with special competence and involvement in emergency and long-term resuscitation. CCM is a multidisciplinary endeavor that crosses traditional departmental and specialty barriers, since no one physician possesses the full range of all skills and knowledge ICU patients may require.”1
So when given the choice, what does it mean to take both? The glass is clearly not half empty, nor half full, and if anything, the clamor surrounding certification and training of critical care physicians provides national attention on the issue. The announcement of ABIM and ABEM opens an opportunity for EM physicians to train in IM-CCM programs, and subsequently certify in CCM. This could be perceived as something that may have potential to cause a rift in the population of current EM-CCM intensivists, or a limitation on what types of CCM future EM physicians may be able to practice. The choice is ours to let this divide our group or not. I am pleased to report on behalf of our working group of EM-CCM Fellowship Program Directors that we have agreed to remain unified. We have chosen to take both: opportunity for training and opportunity for coalescing resources.
We, the Program Directors of CCM Fellowship Programs that train EM physicians, are cognizant that we are the newest group of training programs in town. Fortunately, we have several guidelines to guide the creation of our training programs. In addition to the American College of Critical Care Medicine (ACCM)3 guidelines, we are also using Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC) Requirements2 (Anesthesia-CCM, IM-CCM, Surgical Critical Care), the Multisociety Task Force Recommendations,4 and CoBaTrICE.5 Comparison of these previously published consensus documents show many similarities between expected content, training program requirements, and procedural and resuscitative competencies. We have created a consortium of EM-CCM Fellowship Program Directors that conference call regularly, with the primary goal to ensure that fellowship training is uniform and standard, share best practices, and are critically evaluated. We will be providing future information on our progress, recommendations, and standards regarding EM-CCM fellowship training programs.
Our first task as a consortium is to create standardized curriculum guidelines for our training programs that take into account all of the previously mentioned published guidelines. Our next task will be to share best practices for teaching and assessment of these expected requirements and competencies of our EM-CCM fellowships. Lastly, we intend to standardize and self-regulate our programs, similar to Graduate Medical Education (GME) of large institutions, where regulation of non-accredited training programs already exists. Our working group of Program Directors is committed to the vision that all programs, no matter where its origin, will continue to train EM physicians in CCM. We are especially pleased that the support of our Surgical Critical Care colleagues remains a strong and vitally important component of this consortium. We look forward to the day that the ACGME acknowledges the significant training provided by programs that are currently considered “non-accredited.” We hope that one day, if and when, the ACGME chooses to accredit our fellowships, that we have made their process of evaluation and assessment of our programs smoother.
When faced with situations that may be difficult due to political gain, charged emotions, or conflicts of interest, one must remember to do the one thing that we do daily for patients: first do what is right. Extrapolating that to the future of training in EM-CCM, we know how to compile the best available evidence from decades of previous descriptions of training in CCM. As continued rigor in educational teaching methods and assessment develops in medical education, we anticipate being on the forefront. As methods of assessment, faculty development, and simulation develop, we will be sharing our resources and knowledge amongst our programs. The story of EM-CCM over the past several decades is a natural Outcomes Assessment of the highly successful, non-traditional programs of Shock Trauma and Pitt, where both had the courage to do what was right by the patient and the trainee first. The growth in number of trainees and graduates of EM-CCM is a testament to the foundation provided by EM training and the subsequent development provided by CCM training. Many of these new EM-CCM fellowship programs exist due to these new graduates who, like their hospital administrators, see that doing right by patients first remains tantamount. These physicians will continue to provide excellent clinical care while advancing the training of future EM-CCM physicians.
EM-CCM has traveled quite a long distance in a short period of time, and we will continue to make progress in education, training, research, and clinical care. I have no doubt that the current and future physicians practicing EM-CCM will advance the field in their own individual way. Peter Safar died only a few months after I knew I would be coming to fellowship at Pitt in 2003, but I know that his spirit lives strong, and his rules remain true:
No. 22: It’s up to us to save the world.
References:
- Safar P, Grenvik A. Organization and Physician Education in Critical Care Medicine. Anesthesiology. 1977;47:82-95.
- ACGME Program Requirements for Residency Training in Anesthesiology Critical Care Medicine, Program Requirements for Fellowship Education in Critical Care Medicine, Program Requirements for Residency Education in Surgical Critical Care. www.acgme.org, accessed March 1, 2010.
- Dorman T, Angood PB, Angus DC, et al. Guidelines for critical care medicine training and continuing medical education. Crit Care Med. 2004;32(1): 263-272.
- Buckley JD, Addrizzo-Harris DJ, Clay AS, et al. Multisociety Task Force Recommendations of Competencies in Pulmonary and Critical Care Medicine. Am J Respir Crit Care Med. 2009;180:290-295.
- Competency-Based Training in Intensive Care Medicine in Europe. CoBaTrICE Collaboration. 2006. www.cobatrice.org, accessed March 1, 2010.
- Freedom House. www.freedomhousedoc.com, accessed March 1, 2010
- University of Pittsburgh Medical Center Department of Critical Care Medicine. www.ccm.pitt.edu, accessed March 1, 2010.
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