CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Thomas J. Kulik, MD*,
Therese M. Giglia, MD,
Larry T. Mahoney, MD,
Steven M. Schwartz, MD,
Gil Wernovsky, MD and
David L. Wessel, MD
* C.S. Mott Children’s Hospital, Division of Pediatric Cardiology, University of Michigan Hospitals, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109-0204 (Email: tkulik{at}umich.edu).
Dr. Baden and colleagues argue that our advanced practice in pediatric cardiac critical care training program (1) is insufficient to produce independent cardiac intensivists, and that cardiac patients in the intensive care unit (ICU) must be cared for by board-certified critical care medicine (CCM) specialists. After making the unassailable observation that care of critically ill patients requires multidisciplinary collaboration, they assert the "well-established concept" that this team must be led, or co-led, by someone certified in CCM. Whereas this notion may be congenial to pediatric intensivists, the references they cite (2–6) suggest only that practitioners with special skills best care for such patients; these studies provide no data to indicate what type of program is required to train same.
Indeed, at issue here is not whether special training is necessary, but rather how much. Pediatric CCM specifies three years ( 18 clinical months), but other disciplines require significantly less. Dr. Baden and colleagues point out—by way of showing good examples—that internal medicine, surgery, and anesthesia have pathways for certification in CCM. Indeed, and it turns out that their critical care training programs are quantitatively essentially identical to ours (7–9). Internal medicine requires 11 months of clinical training in critical care beyond subspecialty training (the latter taking as few as two years), but clinical training experience in CCM that occurs during subspecialty training may be applied to the requirements for both subspecialty and critical care training. Dual certification in CCM and cardiovascular medicine is possible with only a total of 30 months of combined clinical training in cardiovascular medicine and CCM. Anesthesia requires 12 months (beyond core anesthesia training) of critical care training, only nine of which must be clinical. For surgery, 12 months of critical care training are required, but up to 25% of that time may be spent in direct operative care of patients. Our training guidelines specify at least nine months of clinical cardiac intensive care training (beyond the three years of pediatric cardiology training), which is clearly commensurate with that required for critical care certification for these subspecialties.
Pediatric CCM opts for 1.5 years of clinical training, perhaps because pediatric CCM trainees have only three years of postdoctoral training as preparation. Our guidelines, however, apply to board-eligible/-certified pediatric cardiologists who, with six years of postdoctoral training, are comparable to trainees in the specialties noted above.
We believe that efforts to gerrymander qualification boundaries to exclude able practitioners from practice work against, rather than foster, a culture of multidisciplinary collaborative care. We who developed these guidelines—including multiple physicians with pediatric CCM certification—did not do so hoping to attain a self-bestowed hegemony for deciding what constitutes acceptable cardiac intensive care training. Rather, we called on many years of experience in an effort to formulate guidelines to prepare a pediatric cardiologist to be expert in managing critically ill cardiac patients, recognizing that various disciplines, such as pediatric CCM, will employ other training models. No doubt cardiac intensivists will benefit from consultation with CCM colleagues, as will also happen in reverse—a robust culture of multidisciplinary care being essential regardless of the pathway chosen to become a cardiac intensivist.
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References
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1. Beekman III RH, Graham TP. ACCF/AHA/AAP recommendations for training in pediatric cardiologya report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Committee on Pediatric Cardiology). J Am Coll Cardiol 2005;46:1380-1403.[Free Full Text]2. Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unitdefining clinical roles and the best practice model. Crit Care Med 2001;29:2007-2019.[CrossRef][Web of Science][Medline] 3. Pollack M, Cuerdon T, Patel K, et al. Impact of quality of care factors on pediatric intensive care unit mortality JAMA 1994;272:941-946.[Abstract/Free Full Text] 4. Pronovost P, Angus D, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients JAMA 2002;288:2151-2162.[Abstract/Free Full Text] 5. Dimick J, Pronovost P, Heitmiller R, et al. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection Crit Care Med 2001;29:753-758.[CrossRef][Web of Science][Medline] 6. Rosenberg D, Moss M. Guidelines and levels of care for pediatric intensive care units Crit Care Med 2004;32:2117-2127.[CrossRef][Web of Science][Medline] 7. American Board of Internal Medicine. Available at: www.abim.org. Accessed March 14, 2006.. 8. Accreditation Council for Graduate Medical Education. Available at: www.acgme.org. Accessed March 14, 2006.. 9. American Board of Surgery. Available at: www.absurgery.org. Accessed March 14, 2006..
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