Surgeons
and Intensive Care Units
(ICUs) are an outgrowth of the recognition by physicians that critically ill patients have special problems, the solutions to which often require the expertise of a wide range of medical and nursing talent. Proficiency in all phases of the care of seriously ill
Intensive
care
units
is rarely, if ever, found in an individual whose has been in any one specialty area. Historically, anesthetists have been the most visible single group of medical specialists involved in the organization and management of combined medical, respiratory, and surgical ICUs. The contributions of our anesthetic colleagues to these units have been immense and are born of their particular knowledge and competence in the management of patients who need resuscitation and complete respiratory support during operations and in the postoperative recovery period. Since most patients who have serious postoperative problems are cared for in ICUs, the management of which is directed by anesthetists, it is appropriate to ask why surgeons should have a role in the leadership of these units. Seriously ill postoperative patients who are admitted to an ICU require close follow-up observation by surgeons. The care of tubes, drains, infected wounds, fluid balance, and the noting of subtle changes in the patient's status that may herald the presence of a leak of an intestinal anastomosis require careful serial observations and judg¬ ment that can only develop through years of meticulous attention to detail. The mature surgeon who manages an ICU is able to use this knowledge and experience to aid in the care of all patients who are admitted to the ICU. Frequently, he or she provides formal or informal consul¬ tation to the busy surgical practitioner on the multitude of problems that may develop in the postoperative period. By virtue of his own surgical background, the surgeon director speaks the same language as his colleagues and shares in the worries and care of the patients. Therefore, the surgeon director is in a pivotal position to use his own knowledge and experience to benefit the critically ill patient. These considerations are key to the question of why surgeons should be involved in the leadership of
patients training
ICUs.
What can management of an ICU give to the surgeon? As director, the opportunities for investigation of the problems of critically ill patients are endless and are limited only by one's imagination and time. Information provided by invasive monitoring generates data that may allow for precise interpretation of the pathophysiologic features of critical illness. The cross-fertilization of knowl¬ edge provided by our anesthetic, medical, and pediatrie colleagues, by virtue of their own special and different backgrounds, provides an unequaled opportunity for growth and learning in these closely allied fields. The personal rewards of working closely with a caring staff of dedicated nurses and respiratory therapists are also
great.
Only a few training programs in intensive care are actually directed by surgeons. A recent tally of ICU training programs (representing only about one half of the available programs in critical care medicine) showed that of 59 fellowship positions offered, only three of the 54 filled positions were occupied by individuals who trained in the base specialty of surgery (Dennis M. Greenbaum, MD, written communication Sept 27,1978). The vast majority of the offered fellowships were filled by individuals who had their training in anesthesia (24 positions) and internal medicine (19 positions). Furthermore, only 14% of the present membership of the Society of Critical Care Medi¬ cine are surgeons.' These statistics indicate a distressing lack of interest by surgeons in this important field. Why is
this? Most medical students are attracted to surgery because the acute nature of many surgical diseases gives a direct and very personal sense of being able to alter significantly the course of an illness through operative intervention. Clearly, good cutting is a dominant part of a smooth postoperative course. What surgeon can be oblivious to the ego gratification of removing an acutely inflamed appen¬ dix and seeing the patient, even with the pain of an incision, feel better on awakening minutes later in the recovery room! Although this may appear to be a digres¬ sion from the theme of the surgeon's involvement in intensive care, it is not. The rewards of the surgeon's
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primary
involvement in an ICU team are there, but they subtle than the example just quoted. They are tempered by the realization that time and energy must be spent on the less dramatic (though no less important) aspects of the preoperative and postoperative manage¬ ment—the drugs, the ventilator, the acid-base balance, and the management of fluids in relationship to the lungs, heart, kidney, and brain. Reluctance on the part of the surgeons to develop the skills necessary to manage ICUs may be engendered in part by the fear that the activities of a surgeon ICU director are mostly nonsurgical. Therefore, the surgeon may worry that his own identity as a skilled surgeon will somehow be forgotten by his medical confreres. In some measure, this is a realistic worry that can only be dispelled by continued interest and personal involvement in the care of patients with surgical problems. It is my conviction that these less "glamorous" aspects of the care of critically ill patients have been to a large extent responsible for the lack of interest by surgeons in assum¬ ing responsibility and leadership for management of units that primarily house their patients. The Society of Critical Care Medicine was founded in 1970.--' Among the purposes of this new organization were the establishment of guidelines for ICU organization5 and physician education in critical care medicine." This organi¬ zation now seeks subspecialty status for individuals whose primary training has been in the traditional areas of anesthesiology, medicine, pediatrics, and surgery.1 This society proposes the establishment of an examination as the basis for a certificate of special competence. Although theoretically a certificate of special competence in critical care medicine7 would have as its purpose the goal of certifying an individual's competence to direct an ICU, it seems uncertain that such an examination would achieve this aim. If one assumes that the body of knowledge necessary for competence in ICU management is equal to the sum of the knowledge of all of the specialties that impinge on the care of critically ill patients, it becomes obvious that it is impossible for any one individual to master it all. Rather than focusing on a certificate of special competence, a goal that may only foster the devel¬ opment of an elitest group, the Society of Critical Care are more
Medicine should concentrate on the educational and train¬ ing aspects of physicians of any specialty who are prepared to devote time and energy to the acquisition of skills that make for leadership. It has been estimated that currently there is a need for 3,000 ICU directors and codirectors to staff the nation's general ICUs in approximately 1,500 general hospitals with more than 250 beds.' It is unlikely that the requirement for passing an examination in critical care medicine will enhance the entry of dedicated physi¬ cians into this field. Specialty status for critical care medicine will doubtless be a much debated topic in the future. Because postoperative problems dominate the patient population of a surgically based ICU, we should encourage the early interest of medical students in this field byoffering elective courses that provide an in-depth exposure to intensive care for periods of one month. During this rotation, the student actively participates in all activities of the ICU. One month is sufficient time for the student to gain initial experience in the principles of fluid manage¬ ment, acid-base balance, and the care of patients requiring ventilation. The interest of surgical house officers in this field also can be fostered by giving them the opportunity to spend part of their surgical training in the ICU, time that will allow them to experience personally the subtle rewards of their participation. In this way, we hope to attract more surgeons into leadership roles in this field. JOHN J. SKILLMAN, MD Boston References 1. Safar P, Grenvik A: ICU patient care responsibility by CCM physician, in Eckenhoff JB (ed): Controversy in Anesthesiology. Philadelphia, WB Saunders Co, 1979. 2. Safar P: Critical care medicine-quo vadis. Crit Care Med 2:1-5, 1974. 3. Shoemaker WC: Interdisciplinary medicine: Accommodation or integration. Crit Care Med 3:1-4, 1975. 4. Weil MH, Shubin H: Symposium on care of critically ill. Mod Med 39:83-137, 1971. 5. Society of Critical Care Medicine: Guidelines for organization of critical care units. JAMA 222:1532-1535, 1972. 6. Society of Critical Care Medicine: Guidelines for physician education in critical care medicine. Crit Care Med 1:39-42, 1973. 7. Grenvik A: Certification of special competence in critical care medicine as a new subspecialty: Status report. Crit Care Med 6:355-359, 1978.
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and Intensive Care Units
(ICUs) are an outgrowth of the recognition by physicians that critically ill patients have special problems, the solutions to which often require the expertise of a wide range of medical and nursing talent. Proficiency in all phases of the care of seriously ill
Intensive
care
units
is rarely, if ever, found in an individual whose has been in any one specialty area. Historically, anesthetists have been the most visible single group of medical specialists involved in the organization and management of combined medical, respiratory, and surgical ICUs. The contributions of our anesthetic colleagues to these units have been immense and are born of their particular knowledge and competence in the management of patients who need resuscitation and complete respiratory support during operations and in the postoperative recovery period. Since most patients who have serious postoperative problems are cared for in ICUs, the management of which is directed by anesthetists, it is appropriate to ask why surgeons should have a role in the leadership of these units. Seriously ill postoperative patients who are admitted to an ICU require close follow-up observation by surgeons. The care of tubes, drains, infected wounds, fluid balance, and the noting of subtle changes in the patient's status that may herald the presence of a leak of an intestinal anastomosis require careful serial observations and judg¬ ment that can only develop through years of meticulous attention to detail. The mature surgeon who manages an ICU is able to use this knowledge and experience to aid in the care of all patients who are admitted to the ICU. Frequently, he or she provides formal or informal consul¬ tation to the busy surgical practitioner on the multitude of problems that may develop in the postoperative period. By virtue of his own surgical background, the surgeon director speaks the same language as his colleagues and shares in the worries and care of the patients. Therefore, the surgeon director is in a pivotal position to use his own knowledge and experience to benefit the critically ill patient. These considerations are key to the question of why surgeons should be involved in the leadership of
patients training
ICUs.
What can management of an ICU give to the surgeon? As director, the opportunities for investigation of the problems of critically ill patients are endless and are limited only by one's imagination and time. Information provided by invasive monitoring generates data that may allow for precise interpretation of the pathophysiologic features of critical illness. The cross-fertilization of knowl¬ edge provided by our anesthetic, medical, and pediatrie colleagues, by virtue of their own special and different backgrounds, provides an unequaled opportunity for growth and learning in these closely allied fields. The personal rewards of working closely with a caring staff of dedicated nurses and respiratory therapists are also
great.
Only a few training programs in intensive care are actually directed by surgeons. A recent tally of ICU training programs (representing only about one half of the available programs in critical care medicine) showed that of 59 fellowship positions offered, only three of the 54 filled positions were occupied by individuals who trained in the base specialty of surgery (Dennis M. Greenbaum, MD, written communication Sept 27,1978). The vast majority of the offered fellowships were filled by individuals who had their training in anesthesia (24 positions) and internal medicine (19 positions). Furthermore, only 14% of the present membership of the Society of Critical Care Medi¬ cine are surgeons.' These statistics indicate a distressing lack of interest by surgeons in this important field. Why is
this? Most medical students are attracted to surgery because the acute nature of many surgical diseases gives a direct and very personal sense of being able to alter significantly the course of an illness through operative intervention. Clearly, good cutting is a dominant part of a smooth postoperative course. What surgeon can be oblivious to the ego gratification of removing an acutely inflamed appen¬ dix and seeing the patient, even with the pain of an incision, feel better on awakening minutes later in the recovery room! Although this may appear to be a digres¬ sion from the theme of the surgeon's involvement in intensive care, it is not. The rewards of the surgeon's
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/05/2015
primary
involvement in an ICU team are there, but they subtle than the example just quoted. They are tempered by the realization that time and energy must be spent on the less dramatic (though no less important) aspects of the preoperative and postoperative manage¬ ment—the drugs, the ventilator, the acid-base balance, and the management of fluids in relationship to the lungs, heart, kidney, and brain. Reluctance on the part of the surgeons to develop the skills necessary to manage ICUs may be engendered in part by the fear that the activities of a surgeon ICU director are mostly nonsurgical. Therefore, the surgeon may worry that his own identity as a skilled surgeon will somehow be forgotten by his medical confreres. In some measure, this is a realistic worry that can only be dispelled by continued interest and personal involvement in the care of patients with surgical problems. It is my conviction that these less "glamorous" aspects of the care of critically ill patients have been to a large extent responsible for the lack of interest by surgeons in assum¬ ing responsibility and leadership for management of units that primarily house their patients. The Society of Critical Care Medicine was founded in 1970.--' Among the purposes of this new organization were the establishment of guidelines for ICU organization5 and physician education in critical care medicine." This organi¬ zation now seeks subspecialty status for individuals whose primary training has been in the traditional areas of anesthesiology, medicine, pediatrics, and surgery.1 This society proposes the establishment of an examination as the basis for a certificate of special competence. Although theoretically a certificate of special competence in critical care medicine7 would have as its purpose the goal of certifying an individual's competence to direct an ICU, it seems uncertain that such an examination would achieve this aim. If one assumes that the body of knowledge necessary for competence in ICU management is equal to the sum of the knowledge of all of the specialties that impinge on the care of critically ill patients, it becomes obvious that it is impossible for any one individual to master it all. Rather than focusing on a certificate of special competence, a goal that may only foster the devel¬ opment of an elitest group, the Society of Critical Care are more
Medicine should concentrate on the educational and train¬ ing aspects of physicians of any specialty who are prepared to devote time and energy to the acquisition of skills that make for leadership. It has been estimated that currently there is a need for 3,000 ICU directors and codirectors to staff the nation's general ICUs in approximately 1,500 general hospitals with more than 250 beds.' It is unlikely that the requirement for passing an examination in critical care medicine will enhance the entry of dedicated physi¬ cians into this field. Specialty status for critical care medicine will doubtless be a much debated topic in the future. Because postoperative problems dominate the patient population of a surgically based ICU, we should encourage the early interest of medical students in this field byoffering elective courses that provide an in-depth exposure to intensive care for periods of one month. During this rotation, the student actively participates in all activities of the ICU. One month is sufficient time for the student to gain initial experience in the principles of fluid manage¬ ment, acid-base balance, and the care of patients requiring ventilation. The interest of surgical house officers in this field also can be fostered by giving them the opportunity to spend part of their surgical training in the ICU, time that will allow them to experience personally the subtle rewards of their participation. In this way, we hope to attract more surgeons into leadership roles in this field. JOHN J. SKILLMAN, MD Boston References 1. Safar P, Grenvik A: ICU patient care responsibility by CCM physician, in Eckenhoff JB (ed): Controversy in Anesthesiology. Philadelphia, WB Saunders Co, 1979. 2. Safar P: Critical care medicine-quo vadis. Crit Care Med 2:1-5, 1974. 3. Shoemaker WC: Interdisciplinary medicine: Accommodation or integration. Crit Care Med 3:1-4, 1975. 4. Weil MH, Shubin H: Symposium on care of critically ill. Mod Med 39:83-137, 1971. 5. Society of Critical Care Medicine: Guidelines for organization of critical care units. JAMA 222:1532-1535, 1972. 6. Society of Critical Care Medicine: Guidelines for physician education in critical care medicine. Crit Care Med 1:39-42, 1973. 7. Grenvik A: Certification of special competence in critical care medicine as a new subspecialty: Status report. Crit Care Med 6:355-359, 1978.
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