Work

The Anesthesiologist in Critical Care Medicine

Year: 2001

Type: article

Abstract: AT the beginning of the new millennium, anesthesiabased critical care medicine (CCM) is at a crossroads.Although anesthesiologists took a leadership role in the initial development of critical care, today the American critical care anesthesiologist is an endangered species, overshadowed in numbers and political clout by colleagues from pulmonary medicine and surgery.In contrast to Europe, where anesthesiologists play a dominant role in critical care, in the United States, anesthesia-based CCM is a peripheral subspecialty of anesthesiology practiced by a small minority.As we seek to broadly redefine the role of the anesthesiologist both inside and outside the operating room, it is timely to ask the question, "Is there a future for anesthesiologists in critical care?"Can we regain a leadership role and thereby enhance our specialty as a whole, or are critical care anesthesiologists doomed to increasing irrelevance as our numbers dwindle toward extinction?This special article is an editorial essay and reflects the observations and thoughts of the leadership of the American Society of Critical Care Anesthesiologists, a component society of the American Society of Anesthesiologists, as well as the perspective of a distinguished European colleague (L.G.). Development of Critical Care Medicine in the United StatesThe neurosurgeon Dr. Walter Dandy (1886 -1946) is credited with establishing the first critical care unit in the country at Johns Hopkins Medical Center.1,2 Anes-thesiologists first took a prominent role in critical care in the United States during World War II, when surgical casualties were grouped together in shock wards.After the war, postoperative recovery rooms became increasingly common and provided the template for today's surgical intensive care units (ICUs).A seminal event in intensive care was the worldwide outbreak of poliomyelitis in the early 1950s.In Denmark, nurses and medical students ventilated patients manually for days, which lent impetus to the engineering and mass production of positive pressure ventilators.Subsequently, respiratory care units spread through the United States, and by 1958, a unit had been established in 25% of hospitals with more than 300 beds.In the early 1980s, an attempt was made to form a conjoint Board of Critical Care Medicine representing anesthesiology, internal medicine, pediatrics, and surgery.However, the component boards could not agree on training qualifications, and the initiative failed.3-5 Instead, in 1986, each individual board established a Certification of Special Competence (Qualifications) in Critical Care recognized by the Board of Medical Specialties and issued by the primary board.The Boards of Anesthesiology and Surgery require 1 yr of critical care fellowship.Pediatric critical care certification requires a 3-yr training program.In addition to offering a separate stand-alone 2-yr critical care fellowship, the American Board of Internal Medicine incorporated critical training into most pulmonary medicine fellowships and extended the fellowship from 2 to 3 yr.6 As a consequence, almost every graduating pulmonary fellow is board-eligible in both pulmonary medicine and critical care.Less than 4% of the 25,000 board-certified anesthesiologists in the United States have the Certificate of Special Competence in Critical Care.Of the 7,800 members of Society of Critical Care Medicine in the United States, approximately 35% are internists, 25% are surgeons, and only 12% are anesthesiologists (fig.1).The relative percentage of anesthesiologists in the Society of Critical Care Medicine has declined over the past decade (fig.2).Membership has also declined in the American Society of Critical Care Anesthesiologists, which was founded in 1986 to represent the specialty within the American Society of Anesthesiologists.Many attribute the diminishing presence of American anesthesiologists in intensive care medicine to the relatively more favorable economic and working conditions

Source: Anesthesiology

DOI: 10.1097/00000542-200109000-00034