I was talking to a friend the other day who told me he was going through his MICU rotation and there was an Anesthesia senior in the MICU that was running it and seemed very confident in his decisions and management. Maybe it's because I've never rotated through a MICU, but I wasn't aware that Anesthesiologists typically ran MICUs.
This is no slam on Anesthesia but I always viewed Anesthesia CC as knowing about surgical patients and managing Surgical ICUs and Medical/Pulm CC doctors knowing medicine and managing Medical ICUs.
My question is, is this typical and do most Anesthesia critical care trained fellows and attendings typically have the knowledge base to run MICUs? I know Anesthesia teaches extensive management of airway, hemodynamics, paralytics, vent control, etc. but I never thought of them as being capable of managing patients with multiple medical comorbidities without the medical background.
Is this a case where Anesthesia CC trained intensivists are capable of running MICUs and SICUs and Pulm CC trained docs can't do the reverse because they're not comfortable with surgical patients?
Yes Anesthesiologists can work in MICUs, but its a problem in training programs. Current ACMGE RRC says that medicine residents can't be supervised by non-ABIM board certified staff. So, ABS (American Board of Surgery) or ABA (American Board of Anesthesiology), the two other boards who offer ABMS critical care certification, certified staff can't supervise medicine residents who will inevitably working in MICUs in training hospitals. That doesn't apply to fellows, however, either way. I worked as an Anes/CCM fellow in a MICU. And the Pulm/CCM fellows who my program worked closely with also worked the Neurosurg and Surgical ICUs under ABA and ABS certified ccm staff.
As far as staff, Pulm/CCM folks also staffed in our surgical and neurosurgical units in addition to the Anes and Surg folks. I can names several other institutions, private and academic, where anes/ccm folks staff MICUs. Stanford (academic), St. Patrick's Hospital, Missoula, MT, St. Vincent Hospital, Billings, MT, both private.
I think in most cases you will find folks sticking to their traditional stomping grounds; Pulm/CCM in the MICU and Anes/Surg/CCM in the surgical units, but that is usually more a function of institution and history than a result of their training. There is a push to keep CCM multidisciplinary, but in many places the ABIM camp is well entrenched and doesn't want to play with others. They've kept that grip with the help of the RRC in academics. There was interesting piece in Critical Care Medicine recently about this, see below.
http://www.ncbi.nlm.nih.gov/pubmed/20029348
Critical Care Medicine:
March 2010 - Volume 38 - Issue 3 - pp 971-972
doi: 10.1097/CCM.0b013e3181c58931
Special Articles
A tale of lutes and ouds: Time to play together in the same key?
Higgins, Thomas L. MD, MBA, FCCM
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Author Information
Chief, Critical Care Division Baystate Medical Center, Springfield, MA; Professor of Medicine and Surgery; Associate Professor of Anesthesiology, Tufts University School of Medicine Boston, MA
Author's note: the lute is the European version of plucked string instruments with a neck and a resonant body with a rounded back. The oud is the Middle Eastern equivalent. The sound of banjo music, of course, is a warning to paddle faster.
The author has not disclosed any potential conflicts of interest.
For information regarding this article, E-mail:
[email protected]
Once upon a time, there was a musician skilled in stringed instruments. In his youth, he had apprenticed with lute players, and after becoming duly certified by the Ancient Bards In Music (ABIM), he went off to make his living as a lutenist. But soon it became apparent that his developing interest in chordally conscious music (CCM) would require yet more training. And thus he traveled to the nation of the crimson hose to study under masters of the oud, who assured him that one could play CCM not only with the lute but also with the oud and even the occasional banjo. In fact, the masters preached multidisciplinary chordal consciousness as an ideal, for such collaboration delighted audiences with its invention and interplay. Whether playing lute, or oud, or mandolin, or even the occasional banjo, the skills of the musician were considered far more important than the specific instrument played. So the musician happily incorporated oud techniques into his lute playing and forthwith became certified by the Aesthetic Bards Association (ABA) with a subspecialty certificate in CCM.
And so it was for many years the musician happily played both lute and oud. As young faculty, he inaugurated a fellowship to train oud apprentices in CCM. The musician flourished, publishing pieces of original music in high-impact journals, and even a textbook or two on CCM. Meanwhile, his apprentices went forth to become certified CCM specialists, with some publishing their own original music and impressive textbooks, and the world was good. Lutes and ouds and mandolins and banjos played in harmony, and audiences applauded.
Time passed, and the musician was invited to move to a concert hall closer to his ancestral home. Lo, there was no apprenticeship in CCM there, and so the musician initiated his second fellowship of CCM for oud players. But there were repeated requests from local lute players (and the occasional banjo player) who also wished to learn CCM. The musician, by now a full Professor of both lutology and oud-playing, consulted his wise chief and was encouraged to also start a CCM fellowship for lutenists. After studying the arcane works of the Ancient Counsel of Great Musical Endeavors (ACGME), he scribed the many, many required sheets of parchment, noting with dismay that the quantity of mandatory scrolls had increased exponentially from just a few years earlier. Remembering the dictums of his mentors that all musicians should play together, he incorporated not only lute players but also oud players and the occasional banjo player into his faculty. Alas, when the parchment was delivered to the Rhythm Review Committee (RRC) of the ACGME describing this grand plan, the wizards informed the musician that some players were not welcome as key faculty, for their CCM certificates were not of the proper color of parchment. Furthermore, our musician, who had inaugurated two oud programs, was further deemed unqualified to lead a CCM program training lute players, for his parchment of CCM certification bore the signatures of oud players rather than lutenists.
Sadly, the musician had to turn over his teaching and mentoring duties to younger musicians possessing the correct parchment, even though his chosen replacement would have been much more productive continuing his successful pursuit of grants from the National Institute of Harmony (NIH). He sighed and signed his approval to divert 25% of his faculty member's time to filling up the voluminous rolls of parchment demanded by the ACGME. Fortunately, apprentice lutenists would still be trained, even if some faculty had to remain off stage in the view of the great wizards of the ACGME.
But across the great land, other musicians also observed that the Ancient Counsel of Great Musical Endeavors, while stating obeisance to the concept of Multidisciplinary Care, had, in fact, hardened their hearts against instructors attempting to train lute players unless their parchment bore the imprint of the Ancient Bards in Music. Verily, the apprenticeship directors at the Society of Chordally Conscious Music meeting publicly bemoaned this development. Yet, the all-powerful wizards permitted no exceptions, regardless of musical reputation, number of scores published in high-impact journals, or demonstrated success in mentoring apprentices. This seemed odd, for CCM practitioners were deemed to be in short supply, and it made little sense to focus on the correct faculty parchment, especially when young apprentices were foregoing the pursuit of CCM for the greater quantity of farthings and guilders available with lifestyle occupations such as skin-tattooing and radiographic iconography. Some claimed that the wizards were fiddling while Rome burned, but it was really just bureaucracy run amok. Oud and lute players alike decried the parochialism within CCM as being meaningless to the patient and detrimental to their care, yet the regulatory bodies continued to promote their unenlightened, myopic agendas.
In the end, nothing was done to foster multidisciplinary spirit, and by and by, the musicians who once played in ensembles featuring lutenists, oudists, mandolin players, and the occasional banjo were replaced by younger musicians who would play only with others who shared the same instrument. The delicate interplay between different instruments was lost, and while all might competently play their prescribed scores, the musicians became less likely to jam, or spontaneously create interesting new harmonies. Thus was the world of CCM impoverished, and the art of collaboration diminished. One can only hope that more enlightened wizards may someday recognize, that among talented musicians, you are what you play, not what your parchment might say.
Keywords:
education; subspecialty training; critical care; Ancient Counsel of Great Musical Endeavors
