Critical care as part of respiratory training in the UK
- 1Department of Respiratory Medicine, St George’s Hospital, London, UK
- 2Department of Medicine and Royal Centre for Defence Medicine, University Hospital Birmingham, Birmingham, UK
- 3Department of Respiratory Medicine, Princess Royal Hospital, Telford, UK
- 4Department of Respiratory Medicine, Northampton General Hospital, Northampton, UK
- 5Programme Director South Thames, Guy’s and St Thomas’ Hospital, London, UK
- Correspondence to:
Dr B C Creagh-Brown
Department of Respiratory Medicine, St George’s Hospital, London SW17 0QT, UK;
Experience in critical care medicine is mandatory for all respiratory trainees in the UK with a need for 60 days (3 months) minimum placement in an intensive care unit (ICU). The Respiratory Critical Care Group of the British Thoracic Society1 recently reported a survey in which there was widespread agreement with this requirement, although it was inadequately provided by a number of programmes. In addition, a proportion of trainees indicated the intention to subspecialise in intensive care medicine and were concerned that their ICU experience was diluted by having responsibilities such as acute general medical takes during their attachment. We recently carried out an email survey of anaesthetic and respiratory trainees and directors of intensive care which provides additional useful information.
The majority of ICUs in the UK operate an admission policy that depends on making initial contact with the duty anaesthetic registrar. One aspect of our survey concerned the interaction between the referring physician and the critical care “gate keeping” specialist. Although it might be optimal to involve the appropriate medical, emergency or surgical consultant directly in making a referral to the critical care consultant, it is often specialist registrars who refer patients, especially out of hours.
Our survey investigated whether the specialty of the referring specialist registrar affected the outcome. A total of 108 doctors (97 specialist registrars and 9 ICU lead consultants) from South Thames, West Midlands and Oxford regions were surveyed in 2006. Of the respiratory specialist registrars, 27% indicated they “commonly” or “always” had difficulty gaining admission for medical patients. No anaesthetic trainee reported difficulty “commonly” or “always” while 47% reported that they “rarely” had difficulty. The different experience may reflect a difference between elective or semi-elective postoperative admissions versus acute medical admissions. Perceived or actual experience in intensive care could be another factor; 48% of respiratory specialist registrars had experience of intensive care medicine at the SHO level compared with 100% of anaesthetic trainees, and all the anaesthetic trainees had experience at the registrar level compared with 52% of the respiratory specialist registrars. Both groups underestimated the duration of critical care experience of each other.
Critical care leads considered that the “quality” of referral was better from specialist registrars in anaesthesia than medicine. They strongly supported the need for physicians to receive more training in how to make effective referrals and in achieving a more “realistic” understanding of potential benefit from ICU admission.
Our survey confirms the common perception that medical teams have more difficulty than anaesthetic colleagues in gaining acceptance of their patients to intensive care. Furthermore, this may relate to the perception that they are less able to judge need or prognosis because they have less ICU experience. Critical care training is soon to be integrated into acute care common stem,2 but additional experience for all medical specialties is probably needed together with an expansion of dual accreditation by medical specialists in intensive care medicine.