Introducing The "Update in Nonpulmonary Critical Care" Series

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Pulmonary medicine has reinvented itself several times over the course of the twentieth century. In 1941 physicians with a special interest in tuberculosis were one of the first groups to break away from the parent specialty of internal medicine and became subspecialists. With the development of effective antimicrobial therapy and the closure of sanatoria, the tuberculosis physician acquired a new body of knowledge and developed skills in pulmonary function testing, bronchoscopy, and, later, polysomnography. This transition took place in most countries around the world. Over the last fifteen years, however, pulmonary medicine has evolved differently in the United States than in other countries. With the exception of New York, almost 90% of physicians in pulmonary training programs now undertake an additional fellowship in critical care medicine (1). Likewise, almost 80% of physicians who have recertified in critical care medicine also hold board certification in pulmonary medicine (1). This experience differs from that in other countries, and the combination of pulmonary and critical care medicine is a hybrid apparently peculiar to America.

That critical care medicine merged with pulmonary medicine probably relates to several factors. Intensive care units (ICUs) were introduced in the 1960s as an area in which to assemble staff and resources for the delivery of mechanical ventilation. With recently acquired, and growing, expertise in respiratory physiology, the post-tuberculosis pulmonary physician had the background to understand mechanical ventilation. These physicians found mechanical ventilation intellectually challenging and the outcome rewarding. Their training in physiology also equipped them to undertake detailed cardiopulmonary monitoringthe other aspect of patient management that differs from the general ward. An attraction of combining the subspecialities is that managing both critically ill and ambulatory patients gives physicians the opportunity to follow the natural history of a disease. This balance between acute care and chronic care also helps physicians avoid and cope with burnout; in their mature years, physicians have the option of increasing their office practice in exchange for the hectic pace of the ICU.

The attraction of combining pulmonary and critical care medicine, however, is countered by the challenge of staying current in such a broad field. At the time of fellowship training in critical care medicine, physicians come fresh from a residency in internal medicine and are familiar with the latest thinking in each of its subspecialties. The graduate of a pulmonary training program leaves with a firm underpinning in pulmonary pathophysiology, which serves as a scaffold for appending new knowledge at a later date. To achieve equivalent expertise in each of the subspecialties forming the infrastructure of critical care medicine is not realistic. The most daunting challenge is to keep abreast of advances in all areas over the four decades between training and retirement. To help beleaguered physicians, we launch a new series, Update in Nonpulmonary Critical Care, in this issue of AJRCCM.

A unique feature of our new series is that each article will be coauthored by a nonpulmonary subspecialist and a pulmonary and critical care physician. The authors are charged with reviewing the most recent advances in a field that has an impact on the care of critically ill patients. Some articles will focus on a single topic, like that dealing with arrhythmias in this month's issue, whereas others will cover several developments in a field. The intent is to revisit a given subspecialty every two years or so, and focus on advances in the preceding period. The nonpulmonary subspecialist is expected to provide the content of each article; the main responsibility of the pulmonary and critical care physician is to define the boundaries and the depth of material covered, and to rope-in a coauthor who strays into arcane minutiae.

Pulmonary and critical care physicians find it challenging to track down the most important new reports in a nonpulmonary subspecialty. Much of the groundbreaking research that later has an impact on critical care medicine is published in a subspecialty journal of that discipline. We would be delighted to receive such articles at AJRCCM, but the reality is that few are submitted to critical care journals. And few of us have the time or the fortitude to scan the journals of every subspecialty. Subspecialty journals publish review articles, but authors write them for comrades rather than for critical care physicians. General medical journals also publish review articles but these are directed towards the general internist. This new series in AJRCCM is designed specifically for physicians practicing critical care medicine. As with all review articles in the Journal, manuscripts in the new series will undergo rigorous peer review by experts who remain anonymous. Only articles satisfying the highest standards will be published.

The teacher-student relationship works two ways, and good teachers have always recognized that the probing questions of a student can deepen a teacher's own understanding. For the middle-aged critical care physician, however, role reversal takes on a new dimension, and the educatee assumes a more active didactic positionit is frequently the resident who points out the latest advances in nonpulmonary fields. As time passes, we are still operating with principles we learned about nonpulmonary fields during our internal medicine residency we do not know which concepts to keep and which to unlearn. As clinicians, we are always susceptible to the temptation of assuming we know most of what there is to be known. This attitude is also common in sciencewitness the transition between Newtonian and quantum mechanics. But knowledge is not fixed, and even pieces of medical knowledge that appear most secure are tentative in nature. A century ago, the pioneering medical educator and founder of Index Medicus, John Shaw Billings (1838-1913), warned medical school graduates, "Your new text books will be antiquated in five years" (2).

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	References

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1. Tobin, M. J.. 1999. Pulmonary and critical care medicine: a peculiarly American hybrid? Thorax 54: 286-287 [Free Full Text].

2. Ludmerer, K. 1999. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. Oxford University Press, New York. p. 9.