hand-and-pen-blog

Gary Masterson, President Elect of the Intensive Care Society

Are we for the sickest or the slightly less sick? When I started my consultant career almost 20 years ago, I worked in my own silo which had high walls constructed to keep us and the outside world apart. The barbed wire at the top of the walls was pretty effective in keeping those meddling single organ doctors (SODs) out.

In those days we didn’t need them because we could do everything ourselves. Sometimes patients got better and we turfed them out with the belief that they all left hospital a couple of days later and returned to their normal lives with eternal gratitude to us for saving them. However, it was always disappointing that so few made the effort to return and say thank you, but it didn’t matter because we knew we were doing a great job.

Becoming the go-to people

The world changed with the publication of Comprehensive Critical Care in 2000. We spread our wings and took our skills to the general wards with outreach teams. We delivered education to the masses through ALERT courses and similar. We all enjoyed the increase in popularity and appreciation from the rest of our hospital colleagues.

The SODs and their minions realised quickly that we were really quite useful people to call upon for help. We became victims of our own success. We fought this trend but probably not strongly enough as they became less and less able to look after even vaguely unwell patients. We were at least partially responsible for their de-skilling.

quote2“I didn’t train to be a palliative care doctor but that is what I spend most of my time doing”

How the world has changed and what a price we have paid for becoming such important cogs in our hospital machines. When I walk the corridors of my hospital in the early hours, I know I am almost certainly the only consultant on site. I have grown weary of being expected to take clinical responsibility for every slightly unwell patient in the hospital.

I didn’t train to be a palliative care doctor but that is what I spend most of my time doing. In fact, no patient in my hospital is allowed the luxury of death unless it is authorised by the duty intensivist. Does that sound familiar?

Now what?

Like it or not, we are where we are. There are on-going conversations about the future of the intensivist role and the structure of intensive care services in general.

quote2“Should we stay as we are, looking after the sickest patients in our units while providing some support to the wards?”

Should we stay as we are, looking after the sickest patients in our units while providing some support to the wards? After all, it would be hard to go back and remove the support we already offer outside of our units. Or should we expand our roles and also look after slightly less sick (level 1+) patients scattered throughout our hospitals.

The reality is that we are not only good at looking after very sick patients, but are also pretty good at identifying deterioration and at preventing slightly ill patients becoming very ill. The latter choice pretends that we currently have the workforce available to take this on which, of course, we don’t.

I know what you’re thinking but here’s the problem – if I were a patient on the general ward and a bit unwell, I would certainly welcome an intensivist having input into, or even directing, my care. Wouldn’t you? When I speak to colleagues about this I hear mixed responses but the balance certainly isn’t 50/50. We need to dictate our own future. One day I might even tell you what I think!

What do you think? The ICS needs to hear your voices to help represent you in these discussions. Tell us what you think by leaving a comment or e-mailing helle@ics.ac.uk (feel free to write in anonymity).

2 thoughts on “The future intensivist

  1. The Future Intensivist – A response

    I remember the ‘critical care’ silo mentality that the president elect refers to. However problems created by so called ‘single organ doctors’, at that time, where not caused by the ‘ologists’ referred to but by the ‘anaesthesia based intensivists’ who created the ‘silo’ mentality by shrouding critical care in the complexities of organ support, jealously guarding the critical care patch and dismissing any attempt by the ‘meddling ologists’ to get involved!

    Let’s not forget that many UK intensivists entered anaesthesia training after one year as a house officer and thus had little experience in the broader aspects of general internal medicine. Whilst accepting the pivotal role of anaesthesia in the genesis of UK critical care we must also now accept that the ‘holistic’ intensivist is more likely to come from a background of general internal medicine training. Indeed I share the views of many who have suggested that critical care medicine should be viewed as the primary specialty rather than some form of ‘bolt-on’ addition.
    All too often I see enthusiastic Foundation trainees who are given the impression that the only route to critical care is through anaesthesia training with an over emphasis on the need for advanced airway skills as the main factor.
    A good anaesthetist does not necessarily make a good intensivist. Similarly, anaesthesia based intensivists are not necessarily the best at delivering safe anaesthesia care to sick or challenging patients!

    I look back on my critical care experience and express a debt of gratitude to all the ‘single organ doctors’ who knocked on my door asking for help. They made me reflect on difficult decisions relating to admission and discharge and especially in consideration of end of life issues.
    There is an inconsistency in many UK ICUs in terms of admission, discharge and EOL care. The widespread practice of ‘demand elasticity’, in terms of bed management, sends conflicting and confusing signals to our medical and surgical colleagues.
    Coupled with the historical inappropriate pessimistic attitude to certain disease groups it does beg the question as to whether UK critical care is the last bastion of medical paternalism?

    Critical care outreach should not be confused with a MERT. There is overlap but ownership of the MERT should rest within the broader acute hospital structure whilst the CCOT should remain as a focus of contact between critical care referrals and discharges.

    Perhaps the greatest challenge facing UK critical care resides with the burgeoning demands of level 2 and 1+ care. This is a problem of our own making with over expansive aspirations to control all level 2 activity, the latter enshrined in the bible of GPICS!

    We need to have a sensible debate about level 2 and 1+ care, accepting that other models of care are sustainable such as the concept of EPOC(enhanced postoperative care) delivered from a shared surgical, anaesthesia platform with critical care input.
    Our colleagues in respiratory medicine have relieved us from an enormous burden with the establishment of non- invasive ventilation units. Renal medicine already provides invasive organ support to an ambulatory population and acute cardiac units should be encouraged to rediscover the art of inotropic support and modes of non-invasive oxygen therapy.

    Given the changes in demographics and increased expectations demanded from healthcare the challenge we face is formidable and requires a broader and more enlightened view if we are to have any prospect of succeeding in delivering sustainable future critical care.

    Dr John Gannon

    Sent from my iPad
    JP Gannon

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