Pulmonary and critical care medicine: a peculiarly American hybrid?*

The evolution of pulmonary medicine over the last 15 years has differed in the United States from that in other countries. Today, most fellow applicants to a pulmonary training programme seek combined training in pulmonary medicine and critical care medicine. Programmes that offer fellowship training in pulmonary medicine alone, without critical care training, are decreasing in number. Of the 2019 fellows trained in pulmonary medicine in the United States over the last five years, 79% obtained their training in a three year combined pulmonary and critical care medicine programme; this number increases to 88% if programmes in New York are excluded.1 Applicants to fellowship programmes that offer training in critical care medicine alone have concurrently decreased. As such, the majority of newly certified pulmonary physicians in the United States also obtain certification in critical care medicine, and vice versa. This experience is very different from that of pulmonary medicine in Europe, and even from that in Canada.

Critical care medicine is one of the most recent disciplines in medicine. The crucible for its development was the polio epidemic in Copenhagen in 1952. An anaesthesiologist, Bjorn Ibsen, found that the combination of careful airway management and positive pressure ventilation—skills previously confined to the operating theatre—resulted in a dramatic reduction in mortality of patients presenting with respiratory paralysis.2 With the focus on airway care and ventilator management, it is not surprising that anaesthesiologists led the way in the introduction of intensive care units (ICUs) and the development of the new discipline of critical care medicine.3 4 In the 1960s and 1970s technological advances pioneered for aerospace research were directly incorporated into intensive care monitoring.5 These technological advances, especially in cardiopulmonary monitoring and treatment, combined with the considerable growth in knowledge of …