Professor Hugh Montgomery considers the evolution of the patients and diseases we manage and worries that training may be too slow to adapt to change.
Some 252 million years ago, the Permian Mass Extinction saw the loss of the 96% of marine life and 70% of terrestrial vertebrate species due to a failure to adapt to their changing environment.
Arguably, the great polio epidemic of 1952 first led to the concept of ‘ICU’, the goal being to deliver life-saving mechanical ventilation. The requirement then was for staff who understood this domain, and that meant anaesthetists.
in those days anyone over the age of 65 went to ‘geriatrics’
As the decades went by, biological understanding rose, therapeutic opportunities advanced and technological savvy increased. It became possible to offer organ transplantation and heart surgery, renal replacement therapy and cardiovascular support. It was this brave and exciting new world I entered in the 1980’s. Patients were young; in those days anyone over the age of 65 went to ‘geriatrics’, and were even denied dialysis. Raging sepsis, cardiogenic shock and ARDS were our bred and butter. There was all to play for and much of what we did was ‘individually experimental’. The ICU world became a broad church, and physicians joined the congregation. Formal training appeared, covering the management of septic shock, ARDS, monitoring and more.
But the world has evolved again. Many ‘ICU diseases’, such as septic shock that needed 120mic/min of norepinephrine, plus vasopressin + methylene blue or ‘classical ARDS’, have all but disappeared. Specialist units now take many patients; stroke, trauma, liver, cardiothoracic, or ventilatory. Elsewhere, the general ICU sees an ageing population plagued by non-communicable diseases. Multiple co-morbidities are the norm. Patient expectations, and the new legal realities, mean that ‘everyone is welcome, and none can be refused’. Changes in experience, training and rotas mean that many patients arrive without an underlying diagnosis; yes, they have type 2 respiratory failure and muscle weakness, but why? For patients such as this, the need is less to understand ARDS or anaesthetics, than to be ‘a general physician par excellence’. Yet training has yet to catch up.
We must also recognise that current specialist training (in any domain) is, in many cases, deeply unattractive.
We must also recognise that current specialist training (in any domain) is, in many cases, deeply unattractive. We are told that 70% of a junior’s life is now spent at a computer dealing with tests. 42% are leaving after FY2. Consultant salaries and lives are no longer seen as the pot of gold at the end of the rainbow. ICM training is no exception to these pressures.
The urgent need, and it is a crisis to be addressed, is to make medical training in general (and ICM training in particular), flexible, relevant and rewarding. The world has changed. We as clinicians and physicians must adapt too, if we, our speciality and our health service, are not to face our own Permian event.