The first discussions about the possibility that intensive care medicine would develop into an independent specialty were somewhat tentative. In 1967 Andrew Hunter (1915-1991) consultant anaesthetist and reader in pharmacology, University of Manchester wrote a Lancet article titled ‗Intensive Care as a specialty‘. His opinion was that ‗intensive care requires a multitude of disciplines. The disciplines are too widely dispersed for a single individual to become competent in them all.‘472
In the following year there was a meeting about intensive care units in the Section of Anaesthetics in the Royal Society of Medicine in London. The session was opened by Professor Anthony (Tony) Dornhorst (1915-2003), Professor of Medicine at St George‘s Hospital, London from 1959-80. Dornhorst was described in Munk’s Roll (the biographies of members of the Royal College of Physicians) as one of the outstanding academic clinician-scientists of his generation.473 He was however, though noted for using novel approaches to solve problems, not impressed with intensive care units. ‗Physicians tend to be unimpressed with the published descriptions of units and their working‘. He criticised the naive idea that survival in an ICU was equivalent to a life saved (it had to be shown that the life was truly at risk or could not have been saved by a competent physician elsewhere). He asked ‗Should specialisation be in terms of the apparatus employed or of the dominant category of disorder affecting the patient? He maintained that anyone who needed it could master a new technique, citing the use of peritoneal dialysis in general medical wards. Thus the right person to treat respiratory failure complicating lung disease is a chest physician, not a respirator expert.‘474
Anaesthetists were not simply respirator experts but were by 1966 recognised experts in respiratory and cardiovascular physiology and had successfully applied their expertise to the management of acute respiratory failure in many pathological conditions. John Robinson, Professor of Anaesthesia in the University of Birmingham reiterated the then-current definition of intensive therapy: the mechanical support of a vital function until the disease process is corrected or ameliorated. He stressed that:
472
Hunter AR. Intensive care as a speciality. Lancet. 1967;2:1151.
473
Royal College of Physicians. Munk‘s Roll. 1998-2004;11:63.
474
Patients in need of this [mechanical support] seldom suffer from derangement of one system; respiratory failure is often associated with renal impairment; cardio-genic shock following infarction may bring both renal and pulmonary ventilation-perfusion defects. These patients require complex electronic and mechanical equipment, but more important is the requirement for sufficient staff with the knowledge and skill to use the equipment to optimal effect. Such patients can no longer be treated in conventional specialist wards of the hospital nor can they be nursed in side- rooms of the general wards by nurses who have infrequent experience in the use of the equipment. They have a much greater chance of survival when treatment is undertaken by a team of medical and nursing staff working in adequate space and with the necessary skill, experience and apparatus.475 Dornhorst was sceptical of medical specialisation in the treatment of the critically ill. He thought the medical specialist who had experience and understanding of the disease should treat the patient. Robinson was maintaining that such specialists should not treat such patients in their own ill-equipped wards and with inexperienced nurses. The description by Boulton of the inadequate treatment by physicians with little understanding of the use of respirators of patients with bulbo-spinal polio supports Robinson‘s contention. But Dewhurst‘s emphasis on the need for those treating respiratory failure to have a deep knowledge of the disease was also justified. It will be seen later in this chapter that a new specialty emerged in which physicians and nurses treating critical illness must be trained in both the physio- pathology of critical illness and the means of treating it.
The need for specially equipped areas of the hospital (units) with specially trained staff was quickly recognised. The first units were opened in England in the late 1950s (Chapter 8). The emergence of a specialist branch of medicine to treat patients needing intensive care took much longer. In 1969 William Mushin and John Lunn wrote that they were unable to accept the notion that the care of patients in intensive care units constitutes a new specialty of medicine ‗to which some have already given the name of intensivism. Since the intensivist‘s experience of any one part of medicine is necessarily limited to the acutely ill he cannot be regarded as a specialist in that entire section of medicine. His knowledge, although it may be broad
475
in extent, is invariably limited in depth. This is not a satisfactory basis for the appellation of specialist.‘ 476
They also felt that the anaesthetist could not be in two places at once; if (s)he is in the operating theatre (s)he could not be in the intensive care unit. They pointed out that there was a shortage of anaesthetists. It was important for them to examine very carefully every new demand for their services. So in their view, intensive care was not a specialty and anaesthetists should not get involved at the expense of their anaesthetic practice. In another article Lunn said that when as a senior lecturer in anaesthesia he was left to run the intensive care unit at Cardiff Royal Infirmary almost on his own, his professor complained that Lunn‘s anaesthetic research was neglected.477
The rapid expansion of intensive care in England and Wales in the 1960s had given rise to these discussions, but no national consensus was reached. As a later paper from the Intensive Care Society stated: nearly every aspect of intensive care has developed as a reactive response to clinical pressures rather than a logical expansion or extension of a service following estimates of future need or changing workload.478 Units were directed and staffed by whoever had the energy and enthusiasm to do so, irrespective of specialty. In fact the majority of units were run and staffed by anaesthetists, sometimes with collaborators from other specialties.479
Training in intensive care medicine
The Intensive Care Society (ICS) was founded in 1970 following an initiative by Alan Gilston (1926-2005). The Society‘s regulations originally stated that not less than 20 percent of members should be from specialties other than anaesthesia. In 1981 seventy percent were anaesthetists, the remainder being from a wide variety of medical specialties and their subdivisions including internal medicine, surgery, paediatrics, clinical physiology and many others.480 The Society publishes its
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Mushin WW, Lunn JN. The anaesthetist and intensive care. Br Med J. 1969;Jun 14:683-4.
477
Lunn JN. The Cardiff Department of Anaesthetics. – a balanced entity. In Essays on the first fifty years 1947-1997. Cardiff: Cardiff Department of anaesthetics and intensive care medicine. University of Wales College of Medicine; 1997. Pages 92-4.
478
Intensive Care Society. 2003. Evolution of Intensive Care in the UK. Available at
http://www.ics.ac.uk/intensive_care_professional/standards_and_guidelines/evolution_of_int ensive_care_2003. Accessed May 2011
479
Stoddart JC. National ITU audit 1992-3. London: Royal College of Anaesthetists; 1993.
480
Gilston A. Intensive care in England and Wales. A survey of current practice, training and attitudes. Anaesthesia. 1981;36:88-93.
Journal, organises meetings and publishes guidelines and standards for equipment and clinical practice. Gilston was secretary-general and initiator of the first World Congress on Intensive Care (1973), and founder, president and secretary-general of the World Federation of Societies of Intensive and Critical Care. He emphasized that the Federation embraced all Societies including single specialty as well as multi- specialist societies. In 1981 a questionnaire was sent to all members of the Society who worked in England and Wales. The results showed that although training in anaesthesia was of a high standard, training in intensive care seemed haphazard and unsatisfactory.
Sheila Willatts, director of intensive care at Bristol Royal Infirmary realised that anaesthetists, although adept at using the techniques required in intensive care medicine, were not widely experienced in general medicine and particularly in diagnosis. She studied for and achieved Membership of the Royal College of Physicians in addition to the Fellowship of the Faculty of Anaesthetists in the Royal College of Surgeons (later the Fellowship of the Royal College of Anaesthetists). The regulations allowed the examinations for the Membership to be taken after one year as a medical registrar. Another year of training in addition to the seven post- registration years required for accreditation as a specialist in anaesthesia deterred most anaesthetists but Willatts was not unique in achieving this double qualification.481 Willatts said in an interview: ‗It was the best thing that I ever did. Intensive care is about ―doctoring‖ at the sharp end and it‘s not really about technology.‘482
Willatts and others realised that the body of knowledge required for the practice of intensive care medicine was not encompassed in the training programme of any existing specialty. In 1983 a survey was conducted of trainees on training in intensive care.483 Because the Department of Health and Social Security did not at that time recognise intensive therapy as a separate specialty, no specialist advisory committee existed and there was no recognised training available for doctors. To obtain the views of trainees in intensive care it was necessary to approach trainees
481
Another known example is Margaret Branthwaite MD, FRCP, FFARCS, Formerly Consultant Physician and Anaesthetist, Royal Brompton Hospital, London and Barrister, Lincoln‘s Inn.
482
Willatts SM. Interview. April 2011.
483
Hillman K, Hinds CJ, Willatts SM. Training in intensive care. A questionnaire to trainees. Anaesthesia. 1983;38:540-5.
(senior registrars (SRs)) in anaesthesia and general medicine. Questionnaires were sent to 343 anaesthetic SRs and 113 were returned. They were also sent to 262 medical SRs and 55 were returned. The low rate of return may have been because many anaesthetic and medical SRs had neither interest nor training in intensive care. The survey showed that of those who responded seventy eight percent of anaesthetists and fifty-one percent of physicians hoped to practise in their parent specialty with an interest in intensive therapy. A sizeable minority had no such interest. The majority of SRs thought that intensive therapy should be a specialty in its own right. The majority in both specialties thought that training should be part of higher professional training and that a period of training in the reciprocal specialty was important. Most respondents thought that training should be more than one year for those hoping to practise their parent specialty with an interest in intensive care and two or more years for prospective full time specialists. Only twenty percent of medical registrars and nine percent of medical senior registrars thought training was adequate whereas 45 percent of anaesthetist trainees in both grades considered their training adequate.
Alan Gilston announced in 1983:
The time for complacency is over. No longer can we assume that an anaesthetist‘s training automatically justifies his continued domination of intensive care in this country, despite his vital role in this work and his outstanding contributions to its development.‘ He described the problems of intensive care in the UK as ‗the explosive and uncontrolled growth in the number of units in the past few years; their haphazard staffing structure; the absence of generally accepted standards of good practice and organisation; the lack of a specially designed training programme for this type of work; the dearth of full-time training posts; the fragmentation of intensive care into highly specialised subdivisions, each jealously guarded by physicians of the relevant specialty; and not least, the virtual absence of a career structure for the aspiring specialist in this field.484
The first sign of an attempt to remedy at least one of the deficiencies in this depressing list was contained in an address by Dr John Nunn to the Faculty of Anaesthetists (of the Royal College of Surgeons) on 17 March 1982 as he demitted
484