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Intensive care in the UK has traditionally been delivered by intensivists within the physical boundaries of the intensive care or high dependency unit. The recent adoption of the term “critical care” reflects an increasing focus on the patient rather than the location or attending physician.1,2 The Joint Committee of Higher Medical Training curriculum in respiratory medicine identifies that experience in “intensive care medicine” is essential for respiratory trainees, and specifies that no less than 60 days should be spent in an intensive care unit recognised by the regional programme director. This is equivalent to 3 months full time training and should ideally be undertaken as a single full time allocation, but can be delivered as blocks of a minimum of 15 consecutive working days, ideally with trainees taking part in the intensive care medicine on-call rota.3
The recently formed Respiratory Critical Care Group (RCCG), a subcommittee of the Education and Training Committee of the British Thoracic Society (BTS), has identified that one of their primary goals is to focus on the interface between respiratory and critical care medicine. The group therefore undertook a survey of respiratory trainees (RTs) and programme directors (PDs) to establish whether the critical care experience prescribed in the curriculum was being delivered. The RCCG sent out questionaires to all PDs and RTs registered with the BTS. The overall response rate was 55% (208/389 RT, 16/18 PD).
Reassuringly, 94% of PDs and 96% of RTs agreed that experience in critical care medicine was an essential part of respiratory training. Furthermore, 90% of RTs were allocated to 3 months training in a recognised unit. However, 41% of RTs also covered acute general internal medicine and/or respiratory medicine during this period, and more than half the PDs attributed local limitations on training to a lack of available posts. Despite this, 85% of trainees reported that their regional training programme included sessions focusing on critical care topics. More interestingly, especially when considering future plans for respiratory and critical care training provision, a number of trainees expressed an intention to develop a specialist interest in intensive care medicine (19%), high dependency medicine (32%), non-invasive ventilation (57%), and weaning (13%).
Accepting the limitations of questionnaires, there are still some key messages that need to be highlighted. Firstly, there is broad agreement between RTs and PDs on the importance of experience in critical care as part of respiratory medicine training, and the majority of RTs have an opportunity to access it. However, 10% of trainees still have inadequate exposure to critical care, either in terms of length of experience or availability of dedicated training, and many trainees are potentially diluting their critical care experience by having to cross-cover for general internal medicine and/or respiratory medicine. Secondly, a significant number of trainees wish to be involved in the delivery of critical care outside the intensive care unit. However, is full accreditation in intensive care medicine necessary to provide this? Probably not, but a longer period of training in intensive care medicine combined with a period of anaesthetics training and experience in a recognised high dependency unit would be acceptable if a competency-based approach were applied.
The provision of critical care services is no longer the sole responsibility of intensivists. However, for RTs to manage critically ill patients effectively outside the intensive care unit, some adjustments may need to be made to training programmes. The obvious question raised is whether training for sub-speciality service provision in this area should be pursued by the BTS? Although this question goes beyond the limits of the current survey, the results do identify that there are a number of RTs dedicated to pursuing a career in the area. The aims of the RCCG will be to support those respiratory physicians practising in this emerging field.
Competing interests: none.
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