Society of Critical Care Medicine 50th Anniversary Review Series: Critical Care Education

Abstract

Critical care medicine (CCM) or intensive care medicine (ICM) emerged from the polio pandemic of the 1950s (1). The first edition of this journal in 1973 recognized the central importance of standardized training in CCM and emphasized the need to change from “traditional vertical or speciality-orientated management...to management by multidisciplinary teams” (2). There are now multiple professional disciplines involved in critical care. However, while the service has evolved to become a key component of hospital care, it has done so in a fragmented manner with widely differing forms of “ownership,” clinical practice, and standards of training and education. In recent years, attempts have been made to harmonize practice and training, but with varying degrees of success. To some extent, this has been attributable to the differing status of “educators,” “doers,” (clinicians) and “researchers.” This had its origins in the 19th century in the central European laboratory-based tradition espoused by Rudoph Virchow: “Medical practice is nothing but a minor offshoot of pathologic physiology as developed in laboratories of animal experimentation”) (3), in marked contrast to the clinical approach of William Osler: “The clinical teachers belong to the fighting line of the profession” (4). Osler’s letter had been stimulated by the publication in 1910 of Abraham Flexner’s report on medical education in the United States and Canada in which Flexner decried the lack of standards in teaching and assessment and the toleration of nonscientific methods of practice. He recommended that medical education should be directed and controlled by university centers of excellence with the appointment of full-time clinical professors (5). Osler disapproved: “I cannot imagine anything more subversive to the highest ideal of the clinical school than to hand over our young men to teachers who are out of touch...with the conditions under which these young men will live.” The tension between Flexner and Osler lay partly in the collision between two competing perspectives of medical education. For Osler, this was an apprenticeship to a craft acquired over many years of practice and observation by clinician role models of impeccable integrity. Apprenticeships were a fiduciary Julian Bion, MD1