The Role Of An Intensive Care Medicine Doctor:
Intensive Care Medicine (ICM) doctors, also termed critical care medicine doctors or intensivists, treat patients with potential, present or recent life-threatening organ system failure.
Examples of conditions managed within an ICM doctors job are heart failure, respiratory failure, sepsis, severe trauma and acute intoxication.1 ICM is a new and evolving specialty that unites competencies from diverse medical specialties to construct a unique approach to critical illness of all forms.
Areas of expertise comprise diagnosis and treatment of acute illness, resuscitation, physiological monitoring, organ support, symptom control, family support and end of life care.2
ICM doctors regularly utilise an array of modalities including pharmacological; bedside diagnostic, for example, echocardiography and ultrasound; ventilation and minor interventional, for example, translaryngeal tracheostomy and intercostal drain insertion. Organising air and road transfer of patients is another responsibility.
Although the work is primarily conducted in hospital Intensive Care or High Dependency Units, ICM doctors provide a consultancy service in emergency settings and inpatient departments regarding the assessment, monitoring and review of critically ill patients.
A multidisciplinary model is employed that features working in close cooperation with, for example, critical care nurses, advanced critical care practitioners, pharmacists, diagnostic laboratory staff and doctors of other medical and surgical specialties. Key skills for ICM doctors are communication, performing under pressure and lateral thinking.
In 2017, 42% of ICM doctors were female.3 Most ICM doctors are dually accredited, and work, in ICM and a partner specialty, for example, anaesthesia, emergency medicine and respiratory medicine.1
The proportion of time devoted to each specialty is in accordance with individual preference or service interests. In future, the role of ICM doctors is likely to change as a result of modifications in health service provision, for example, centralisation of specialist surgery, trauma and emergency care.
A Typical Week:
ICM doctors may work full-time or part-time with another specialty. A standard day commences with a multidisciplinary handover that features detailed discussion on patients’ progress.4 Subsequently, ward rounds are conducted to facilitate the review and development of treatment plans.
Typically, trainees perform procedures and reviews and consultants engage in teaching and supervision of more complex procedures. ICM doctors are responsible for between 8 and 25 patients at a time and Intensive Care Units operate 24 hours a day.
An on-call pattern of between 1 in 8 and 1 in 12 shifts may be followed.4 On average, ICM doctors work no more than 48 hours per week, according to ‘Working Time Regulations 1998’.
The Route To Intensive Care Medicine:
The route to ICM commences with the attainment of a medical degree and two years of foundation training. Subsequently, there is core training. Trainees choose between Internal Medicine Training (IMT) stage 1, Core Anaesthetic Training (CAT) and Acute Care Common Stem (ACCS).
All the ACCS pathways – Acute Medicine, Emergency Medicine and Anaesthetics – are suitable.5 IMT and ACCS are three-year programmes. In 2019, the competition ratios for ACCS Acute Medicine/IMT CT1, ACCS Anaesthetics/Anaesthetics CT1 and ACCS Emergency Medicine ST1/CT1 were 1.43, 2.35 and 2.14 respectively.6 IMT features rotations across a selection of medical specialties and is concluded by the Membership of the Royal College of Physicians of the United Kingdom (MRCP (UK)) examination.
ACCS is a similar programme but, in the initial two years, greater focus is assigned to acute medicine, emergency medicine, anaesthetics and ICM. The final year of ACCS is devoted to the parent specialty of the pathway. Entry to the final years of IMT and ACCS are competitive if there is intention to pursue ICM. ACCS Acute Medicine trainees must also pass the MRCP (UK) examination. ACCS Emergency Medicine and ACCS Anaesthetics trainees must pass the Membership of the Royal College of Emergency Medicine (MRCEM) and the Primary Fellowship of the Royal College of Anaesthetists (FRCA) examinations respectively.5
CAT is a two-year programme that comprises rotations that allow the acquisition of experience in core anaesthesia, patient assessment, resuscitation and ICM and is also concluded by the FRCA examination. Alternatively, trainees that have completed the initial three years of Emergency Medicine run-through training are also eligible to enter ICM higher specialty training.2
Higher specialty training in ICM has a minimum duration of five years. In 2019, the competition ratio for ICM ST3 was 1.78.6 The programme has three stages and is a spiral curriculum. The first stage, which is the four years from CT1 to ST4, aims to reinforce knowledge and skills in general diagnosis and patient management and bring trainees from all the various core training programmes to the same standard.2
Stage 1 features a year in each of anaesthesia, medicine and ICM. Stage 2 enables trainees to pursue an area of special interest, for example, paediatric, neurosurgical and cardiothoracic ICM. Trainees also develop an area of expertise. Examples include research, quality improvement, paediatric intensive care and cardiac intensive care.
Trainees must pass the Fellowship of the Faculty of Intensive Care Medicine (FFICM) final examination prior to progressing to the last stage of training. Stage 3 is based in Intensive Care Units and allows trainees to acquire skills consistent with independent practice as a consultant.2
Finally, trainees are awarded a certificate of completion of training (CCT) by the General Medical Council (GMC). Consultant posts may be applied for six months prior to attainment of a CCT. This is an expanding specialty; demand for consultants increases yearly.
It is more common for trainees to attain dual accreditation in ICM and a second specialty. Presently, in accordance with GMC approval, the second specialty can be acute medicine, anaesthetics, emergency medicine, renal medicine or respiratory medicine.2
These programmes have been chosen as they allow trainees to acquire full competencies in both specialties without extensive prolongation of training. In the dual programmes, special areas training is replaced with training in the second specialty. The training period, that is core training and higher specialty training, is extended to eight and a half years.
Medical students interested in pursuing a career in ICM can attend conferences, join student societies and choose special study or research modules with a focus on ICM. An early decision on specialty choice may be of use and can be aided by careful observation and enquiries on clinical placements.
Foundation trainees should attempt to secure full placements in ICM or, if unfeasible, taster experiences or a full placement in a related discipline, for example, anaesthesia, acute internal medicine or emergency medicine.
Alternatively, it may be possible to undertake a third foundation year as a clinical fellow in ICM. Teaching, research, audit and management experiences are favourable for foundation and core trainees.
All trainees on the single CCT programme develop expertise in an area of interest during stage 2 of higher specialty training. Additionally, there are two ICM subspecialties: Pre-hospital Emergency Medicine (PHEM) and Paediatric Intensive Care Medicine (PICM).
PHEM is a novel subspecialty engaged in the provision of critical care to seriously ill or injured patients outside the hospital environment, for example, at the incident scene or during emergency transfer to or between hospitals.7 Uniquely, doctors of this specialty navigate hazards at incident scenes, environmental challenges, resource limitations, diverse caseloads and solitary working conditions.
Entry to the PHEM training programme is via competitive application during stage 1 of higher specialty training.2 The subspecialty training takes place during the special skills year and there is no extension of the overall period of training.
PICM doctors resuscitate, stabilise, treat and transfer seriously ill or injured children in emergency, transfer and intensive care settings.8 Similar to PHEM, PICM training commences during the special skills year and does not result in prolongation of the total training period.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020, the salary bands range from £77,779 to £109,849.9 Salaries can be further enhanced with NHS excellence awards.
There is some private practice earnings potential in ICM, but this is significantly less than the NHS salary.10
The recommended starting salary of accredited consultants in the British Army is similar to that in the NHS. In 2017, this was £80,527.
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
In the UK, the professional and statutory organisation for ICM is the Faculty of Intensive Care Medicine (FICM) and the key society is the Intensive Care Society. Additionally, there is the European Society of Intensive Care Medicine (ESICM). The FICM hosts an annual meeting and the ESCICM hosts two annual congresses.
Key journals in the discipline are Intensive Care Medicine, Critical Care Medicine and the American Journal of Respiratory and Critical Care Medicine.
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Curriculum for a CCT in Intensive Care Medicine [Internet]. The Faculty of Intensive Care Medicine; 2019 [cited 11 September 2020]. Available from: https://www.gmc-uk.org/-/media/documents/cct-in-icm-part-i---handbook--2019-v2_4--final_pdf-77718175.pdf
NHS Digital. Analysis of the representation of women across the hospital and community health services workforce [Internet]. NHS Digital; 2018 [cited 11 September 2020]. Available from: https://digital.nhs.uk/data-and-information/find-dataand-publications/supplementary-information/2018-supplementaryinformation-files/analysis-of-the-representation-of-women-across-the-hospitaland-community-health-services-workforce
Working life (ICM) [Internet]. Health Careers. [cited 11 September 2020]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/intensive-care-medicine/working-life
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Sub-specialty Training in Pre-hospital Emergency Medicine [Internet]. Intercollegiate Board for Training in Pre-hospital Emergency Medicine; 2015 [cited 11 September 2020]. Available from: https://www.gmc-uk.org/-/media/documents/cct-in-icm-part-i---handbook--2019-v2_4--final_pdf-77718175.pdf
Paediatric intensive care medicine - subspecialty [Internet]. Royal College of Paediatrics and Child Health. [cited 11 September 2020]. Available from: https://www.rcpch.ac.uk/resources/paediatric-intensive-care-medicine-sub-specialty
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Morris S, Elliott B, Ma A, McConnachie A, Rice N, Skåtun D et al. Analysis of consultants' NHS and private incomes in England in 2003/4. Journal of the Royal Society of Medicine. 2008;101(7):372-380