Dr Gumersindo Gonzalez Diaz
Unidad de Cuidados Intensivos, Hospital Universitario
Morales Meseguer, Murcia, Spain
This article describes the development of intensive care medicine in Spain as a primary speciality and its specific, five-year training programme, initiated in 1979.
The idea of grouping critical patients in a common area was a natural result of the advances of medicine. The configuration of intensive care medicine as a new speciality was gradually justified by the evidence of homogeneous physiopathological and clinical characteristics in critically ill patients from different backgrounds. In addition, intensive care medicine filled the need to incorporate new therapeutic strategies and technological developments.
Definition of the Speciality
Intensive care medicine is defined as that part of medicine which deals with patients who suffer physiopathological alterations that have reached such a level of severity that they represent a current or potential threat to the patient’s life, but who may, nevertheless, recover. Intensive care units (ICUs) are the main places where the work of this speciality is done. They are multidisciplinary, central service centres that operate in close collaboration with the rest of the hospital and treat both medical and surgical patients. Critical care may be performed in the ICU, intermediate care unit or emergency room and at any location where criticalcare may be necessary, especially during transport of a critically ill patient or a disaster situation (Murillo et al. 2003).
Overview of Intensive Care Training
In Europe, the national intensive care training programmes show diversity in access, structure, regulation and assessment, making it difficult to recognise this specialty from one European state to another. It should be necessary to establish a common minimum standard of training throughout the European Union. The Competency-Based Training in Intensive Care in Europe (CoBaTRICE) project, a project of the European Society of Intensive Care Medicine (ESICM), strives for a consensus to harmonise a common core curriculum in the European Union’s member states and promotes the need to establish an international agreement about a common “end product.”
The most common structure of training in Europe is the supra-speciality model, which permits multidisciplinary access to a common intensive care medicine training programme. In contrast, in the primary speciality model, intensive care medicine is an independent speciality, which can be accessed directly after undergraduate medical training. Switzerland and Spain are the two best examples of this model in Europe.
Intensive Care Training in Spain
In our country, anaesthetists and internists were the primary specialists involved in critical care until 1978.That year, legal regulation established intensive care medicine as a primary speciality, named Medicina Intensiva (Intensive Care Medicine), with a specific postgraduate training programme (whose interns and residents are referred to as MIR) (Esteban et al. 1987; Esteban et al. 1993). The total training period for Medicina Intensiva was set at five years. In 1979, the first generation of MIR began training, obtaining their official qualification in 1984. In those years, it was only possible to pursue primary specialities, without an option for supra- or sub-speciality.
The National Commission of Medical Specialities, under the Spanish Health Ministry, regulates training and recommends diplomas for approval by the Education Ministry (Law 44/2003). The intensive care medicine commission, which incorporates both ministries and helps regulate intensive care training, is composed of eleven members elected from among prestigious professionals to fill the following positions:
• Four members appointed by the Health Ministry’s commission of human resources,
• Two members appointed by the Education Ministry,
• Two members appointed by the Spanish Society of Intensive Care Medicine (SEMICYUC),
• Two members representing residents (trainees) of the speciality, and
• One member representing the General Council of Medical Colleges.
The first two years of general medical training are dedicated to rotations in the hospital’s departments of internal medicine, medical specialities and emergency medicine. Tutorial and supervision of the training programme is conducted by the head of service and the trainee’s tutor within the teaching ICU. During the three years of specific intensive care training, a minimum of 70% of the student’s time is dedicated to the ICU. The training status of an ICU is based on the ability of the ICU to offer complete training and on the basis of the number and kind of patients treated, human and material resources, ICU structure, research capacity and scientific output. All intensive care training objectives are completed under a regime of progressive responsibility. The evaluation of the trainee is done each year in a timely manner by tutors, staff and the head of service. Ultimately, a diploma for the successful candidate is recommended by the Health Ministry and approved by the Education Ministry.