It is impossible to talk about an international perspective without a brief look at historical developments. Critical care has its origins in the establishment of special recovery areas for postoperative patients. Most notably in this country, Johns Hopkins opened a neurosurgery unit in 1923 and Peter Bent Brigham a cardiac unit in 1956. World War II necessitated the creation of trauma units, and a worldwide polio epidemic in the 1950s stimulated the development of special ventilatory units to increase patient survival.

Anesthesiologists were instrumental in the development of the tank ventilator, and their expertise with the technology and therapeutic skills quickly earned them high regard as clinicians all across Europe. Several European physicians such as Ake Grenvik, M.D., and Henrik Pontopiddan, M.D., were pioneers in establishing anesthesiology and critical care in this country. Despite anesthesiologists’ early involvement, to date, the American Board of Anesthesiology has certified 36,458 candidates in anesthesiology but only 1,098 in critical care medicine.¹ This is in sharp contrast to developments around the world.²

Although critical care in Africa as a whole is poorly developed, South Africa has an established two-year critical care curriculum, and anesthesiologists predominantly direct their intensive care units (ICUs). Across Asia, Japan has a five-year single specialty and a shorter supra-specialty track for critical care with more than 50 percent of ICUs directed by anesthesiologists. The origins of Korean critical care have been in the form of anesthesia short courses provided by the United States as well as training in Denmark, supported by the World Health Organization. As a result, almost all Korean academic centers have anesthesiology-based critical care medicine providers. India is in the process of establishing formal training and certification in critical care, an effort spearheaded mainly by individuals who have studied in the United States. Training and certification requirements vary across Southeast Asia, with Taiwan, Indonesia, Thailand and the Philippines all mandating both, while former colonies such as Hong Kong have adopted more stringent, common education and examination pathways with the Australia-New Zealand Intensive Care Society (ANZICS). Anesthesiologists make up almost 90 percent of ANZICS’ membership.

With more countries joining the European Union, efforts to develop common core curriculum for critical care medicine have intensified. Although anesthesiologists still constitute the majority of ICU directors, the pathways differ considerably. Spain, Poland and Romania, for instance, all have five- to seven-year single-specialty curricula. Germany has a common two-year track accessible to physicians from a variety of specialties; but at a minimum, every anesthesiology resident must complete at least six months in the ICU and an additional 18 months for subspecialty certification. More than 85 percent of Germany’s ICUs are directed by anesthesiologists. In Italy anesthesiology is critical care medicine; a mandatory base year in the ICU is followed by at least two additional months of CCM for every year of anesthesiology training.

CCM is considered an exclusive anesthesiology subspecialty in the Czech Republic, Slovenia, Turkey, most of Scandinavia and many Arab countries. Austria, Belgium, France, Greece, Ireland, Israel, the Netherlands, the United Kingdom, Portugal and Switzerland have common, multidisciplinary training programs that follow base specialty training. As of October 2003, nearly 30 European countries have embarked on the ambitious three-year project to establish a Competency-Based Training in Intensive Care Medicine in Europe, or CoBaTrICE. It is designed not to interfere with current education but instead to help define minimum competencies for a specialist, thereby facilitating common standards of training and free movement across borders.³

Canada also features a two-year common pathway into the subspecialty of critical care medicine accessible through several base specialties. The graph above illustrates the differences in membership of anesthesiologists (in percent) in four major international critical care societies.⁴

As most ASA members know, the current U.S. anesthesiology curriculum requires only a two-month experience in the ICU — that is the least amount of formal ICU experience in anesthesiology training anywhere in the world. In addition anesthesiologists direct less than 5 percent of our ICUs. So when it comes to anesthesiology-based intensivists, the United States is quite clearly the odd one out.


References:

1. Personal communication with ABA Executive Office.

2. Kvetan V, Vincent JL, Dobb GJ, eds. International perspectives on critical care. In: Critical Care Clinics. Philadelphia: W.B. Saunders Co; 1997.

3. CoBaTrICE. <www.pickereurope.org/research/Cobatrice_flyer_Oct_03.pdf4>.

4. <www.anzics.com.au>; <www.esicm.org>; <www.lhsc.on.ca/critcare/ccc/>; <www.sccm.org>.

Heidi B. Kummer, M.D., Ph.D., is an anesthesiologist and Master’s degree candidate at Boston University School of Public Health, with concentration in bioethics.