PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1856-1857 (doi:10.1542/peds.2006-0414)
Intensivist-Led Team Approach to Critical Care of Children With Heart Disease: In Reply
Thomas J. Kulik, MDC. S. Mott Children's Hospital
Division of Pediatric Cardiology
Department of Pediatrics
University of Michigan Hospitals
Ann Arbor, MI 48109-0204
Therese M. Giglia, MD
Department of Pediatrics
Schneider Children's Hospital
New Hyde Park, NY 11040
Larry T. Mahoney, MD
Department of Pediatrics
University of Iowa
Children's Hospital of Iowa
Iowa City, IA 52242
Steven M. Schwartz, MD
Department of Pediatrics
Cincinnati Children's Hospital
Cincinnati, OH 45229
Gil Wernovsky, MD
Department of Pediatrics
Children's Hospital of Philadelphia
Philadelphia, PA 19104
David L. Wessel, MD
Department of Cardiology
Children's Hospital of Boston
Boston, MA 02115
Baden et al argue that our advanced practice in pediatric cardiac critical care training program1 is insufficient to produce independent cardiac intensivists and that cardiac patients in the 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. Although this notion may be congenial to pediatric intensivists, the references they cite2–5 suggest only that practitioners with special skills best care for such patients; these articles provide no data to indicate what sort of program is required to train them.
At issue here is not whether special training is necessary but rather how much. Pediatric CCM specifies 3 years (
18 clinical months), but other disciplines require significantly less. Baden et al 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.6–8 Internal medicine requires 11 months of clinical training in critical care beyond subspecialty training (the latter takes as few as 2 years), but clinical training experience in CCM, which 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 9 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 9 months of clinical cardiac intensive care training (beyond the 3 years of pediatric cardiology), which is clearly commensurate with that required for critical care certification for these subspecialties.
Pediatric CCM opts for 1 years of clinical training, perhaps because pediatric CCM trainees have only 3 years of postdoctoral training as preparation. Our guidelines, however, apply to board-eligible/certified pediatric cardiologists who, with 6 years of postdoctoral training, are more comparable to trainees in the specialties noted above.
Baden et al also think that the process of formulating these guidelines was flawed because, in so many words, CCM leadership neither helped create nor was required to approve them. We can only assume that they are concerned that our guidelines therefore must lack a critical care perspective, but we should note that 3 of the primary authors of the guidelines are certified in CCM and that the guidelines were formally reviewed, modified, and approved by the Pediatric Cardiac Intensive Care Society (this group has >300 members, many with CCM certification). We also discern a striking asymmetry in the argument from Baden et al that CCM practitioners believe that their critical care training qualifies them as "team leaders" for taking care of critically ill cardiac patients; yet, at least as far as we are aware, the CCM training curriculum was developed without "careful and collaborative forethought" with pediatric cardiac medicine specialists (cardiologists). Because issues stemming from cardiovascular anatomy, physiology, and electrophysiology (not infrequently arcane and complex) are often the major determinants of a cardiac patient's clinical status, it is hard to understand why the CCM community is qualified to independently formulate training guidelines for providing cardiac critical care but the cardiology-based critical care community is not.
We think 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 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 other disciplines such as pediatric CCM will use other training models. There is no doubt that cardiac intensivists will often benefit from consultation with CCM colleagues, as will also be the case in reverse. A robust culture of multidisciplinary care is essential regardless of the pathway chosen to become a cardiac intensivist.
REFERENCES
- Graham TP Jr, Beekman RH 3rd; American College of Cardiology Foundation; American Heart Association; American College of Physicians, Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology). Training guidelines for pediatric cardiology fellowship programs.
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[Free Full Text] - Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med. 2001;29 :2007 –2019[CrossRef][Web of Science][Medline]
- Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. Impact of quality of care factors on pediatric intensive care unit mortality.
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[Abstract/Free Full Text] - Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients.
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[Abstract/Free Full Text] - Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. 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]
- American Board of Internal Medicine. Policies for added qualifications in critical care medicine. Available at: www.abim.org/cert/policies_aqccm.shtm. Accessed March 14, 2006
- Accreditation Council for Graduate Medical Education. Program requirements for residency education in surgical critical care (surgery). Available at: www.acgme.org/acWebsite/downloads/RRC_progReq/442pr701_u305.pdf. Accessed March 14, 2006
- Accreditation Council for Graduate Medical Education. Program requirements for residency education in anesthesiology critical care medicine. Available at: www.acgme.org/acWebsite/downloads/RRC_progReq/045pr101.pdf. Accessed March 14, 2006
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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