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Commentary |

Establishing Pulmonary and Critical Care Medicine as a Subspecialty in ChinaPulmonary and Critical Care Medicine in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians FREE TO VIEW

Renli Qiao, MD, PhD, FCCP; Mark J. Rosen, MD, FCCP; Rongchang Chen, MD, FCCP; Sinan Wu, MD; Darcy Marciniuk, MD, FCCP; Chen Wang, MD, PhD, FCCP; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup*
Author and Funding Information

From the Department of Pulmonary and Critical Care Medicine (Dr Qiao), Keck School of Medicine, University of Southern California, Los Angeles, CA; the American College of Chest Physicians (Drs Rosen and Marciniuk), Northbrook, IL; Department of Medicine (Dr Rosen), Hofstra North Shore-LIJ School of Medicine, Hempstead, NY; the Department of Clinical Medicine (Dr Chen), First Affiliated Hospital of Guangzhou Medical College, Guangzhou Institute of Respiratory Diseases, Guangzhou, China; Beijing Hospital (Dr Wu), Ministry of Health, Beijing, China; the Division of Respirology, Critical Care, and Sleep Medicine (Dr Marciniuk), University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada; and the Chinese Thoracic Society (Dr Wang), Beijing Hospital, Ministry of Health, Beijing Institute of Respiratory Medicine, National Clinical Research Centre for Respiratory Medicine, Beijing, China.

Correspondence to: Chen Wang, MD, PhD, FCCP, Beijing Hospital, Ministry of Health, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, National Clinical Research Centre for Respiratory Medicine, No 1 DaHua Rd, Dongcheng District, Beijing 100730, China; e-mail: cyh-birm@263.net


*Members of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup are listed in e-Appendix 1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(1):27-29. doi:10.1378/chest.13-2082
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This commentary heralds the recognition in China of a new subspecialty, Pulmonary and Critical Care Medicine, and the first national fellowship training pathway in any medical specialty. Because of striking environmental health-care similarities that existed in the United States, the Chinese medical community decided to model the specialty after that in the United States. Because of its expertise in educating pulmonary and critical care physicians in the United States, the American College of Chest Physicians was chosen by the Chinese Thoracic Society, with the approval of the Chinese government, to help with the transformation of this new specialty. A work group representing the two societies is collaborating to reorganize ICUs within a select group of large teaching hospitals in China and to introduce standardized and rigorous training in pulmonary and critical care medicine as a national program.

The evolution of pulmonary medicine in China has been described as occurring in three phases.1 The first, from the 1920s to 1960s, focused on TB; the second (1970s to mid-1990s) was directed primarily at prevention and treatment of common diseases like COPD and cor pulmonale and saw the start of hospital departments of respiratory medicine. As in the West, Chinese physicians recognized the urgent need to provide high-quality critical care in the face of increasing demand in an aging population of > 1.3 billion (19% of the world’s population) who had complex and comorbid illnesses. Chinese pulmonologists are responding with the current third phase of development, namely, expanding the scope of respiratory medicine to encompass critical care medicine (CCM).

Respiratory medicine was the driving force behind the informal development of CCM and ICUs in China.2 In the 1970s, Chinese pulmonologists started intensive care programs to care for patients with cor pulmonale. Since the late 1980s, many hospitals with adequate resources began to set up respiratory ICUs and, thus, began a more formal practice of CCM. Entering the 21st century, and especially after the SARS epidemics in 2003, the field of CCM and the expansion of ICUs accelerated. From 2005 to 2011 in Zhejiang Province, the number of ICUs grew to 171 (a 19.5% increase), and the total number of ICU beds increased to 2,579, a 134% increase.3

Currently, most ICUs in China are referred to as “integrated,” where patients with a variety of medical and surgical conditions are cared for by a single team. This model evolved because prior lack of financial resources allowed only for the development of single units. More recently, medical and surgical specialties have grown rapidly, coupled with the demand for higher quality of medical care. These phenomena exposed the limitations in the training and expertise of intensivists and the inadequacy of “integrated ICUs,” as they still commonly exist, to provide high-quality critical care.

There are now no formal or consistent pathways to train and develop experience in CCM. Most intensive care physicians in China come from the ranks of recent graduates in general internal medicine programs, along with more senior pulmonologists, cardiologists, and anesthesiologists. Some other intensivists may come directly from medical schools, some with no specific training in critical care at all. Although there is a standard examination at the end of pulmonary and critical care training, some criticize it for not being challenging enough to reflect the realities of practice.

Like every other country, China faces the challenge of providing consistent and effective evidence-based care to its people. This is especially problematic for intensive care owing to its high cost and limited clinical workforce. Improving the quality of care depends on reducing variation in practice, but critical care medicine in China is organized according to each institution’s resources and needs. This inevitably results in wide variations but also offers great opportunities for improvement.

The Chinese professional community has recognized that standardized training and practice in all of the specialties is essential for the medical system and, most importantly, for patients. A passionate advocate for standardization is Renli Qiao, one of the coauthors of this article, who has had experience as an intensivist in both China and the United States. To highlight his argument, he developed a series of publications in the Chinese Thoracic Society journal and presentations at their national meetings in which he described how US intensive care services faced similar issues as those in China and how the subspecialty of pulmonary and CCM (PCCM) was established and evolved in the United States over the last 3 decades.46

In the United States, the integration of critical care into the subspecialty of pulmonary medicine was driven largely by workforce issues. On the premise that caring for critically ill patients is best achieved by knowledgeable and skilled staff in specialized ICUs, the need to develop an organized system that applies standardized, evidence-based, and timely intensive care was recognized.7 A collaboration among the four major US critical care professional societies assessed and reported on the patterns of care for patients with critical illness and pulmonary disease, the anticipated demand for intensive care in the future, and the ability of the workforce supply to meet those demands. After analyzing information on the population, patients, and hospitals in 1997, and conducting surveys of ICU directors, critical care physicians, and pulmonary physicians, the authors found that only 37% of patients in the ICU received care by trained intensivists and that the demand for intensivists would continuously and rapidly grow, but the supply of intensivists would remain constant.8

At the urging of the ACCP and other professional societies, the US Congress called for an examination of the rapidly widening gap between the aging of the population and the number of critical care physicians. After assessing the state of physician training and practice, and trends in the organization and delivery of care, a 2006 report described the growing disparity between supply of critical care physicians and demand through the year 2030. As demand increased progressively, the supply of intensivists was projected to remain constant, at best.9

At the time of the report, pulmonologists were clearly the dominant component of the US critical care workforce and were projected to continue to be so. In 2004, 72% of the 1,374 fellows in all of the accredited US critical care fellowship programs, and 88% of those with a background of internal medicine, were training in combined PCCM programs. By 2012, the total number of critical care fellows increased by 30% to 1,786; PCCM fellows still composed 88% of all with primary certification in internal medicine and represented 77% of all critical care trainees. Surgeons, whose critical care practice is generally limited to the perioperative period, accounted for only 9.7% of all US critical care trainees, and anesthesiologists accounted for 2.7%.10

The place of PCCM physicians as the great majority of critical care providers most likely arises from the overlap of the requisite knowledge and skills of pulmonary and critical care physicians. Critical care is by nature based in physiology and the complexities of acute and multisystem illness, and is, thus, based in internal medicine more than surgery, anesthesiology, and other specialties. Internists also have more training and experience in longitudinal management of patients with medical comorbidities and are more likely to use a comprehensive and integrative approach to care rather than focusing on single organ systems. Pulmonary medicine has always had a central role in intensive care, because respiratory failure is usually a major feature of the critical illness.

Professional factors were also important in the ongoing integration of pulmonary and critical care medicine in the United States. Practicing CCM is perhaps the most common reason that young physicians decide to pursue careers in PCCM. In a survey of internal medicine residents at three US university hospitals, they cited intellectual stimulation, care of critically ill patients, application of complex physiology, and ability to perform procedures as the most attractive features of that career.11

The drive to establish PCCM as a subspecialty in China parallels the evolution of the field in the United States. As in the United States, pulmonary medicine started as an outgrowth of “phthisiology,” the study of tuberculosis. In a 1999 editorial, Tobin and Hines12 speculated that “newly qualified pulmonologists in the United States regard the practice of pure pulmonary medicine as an anachronism of a bygone era in the way that those of us who graduated from training programs in the 1980s viewed the subspecialist in tuberculosis.” As in China, pulmonary medicine in the United States evolved when phthisiologists first expanded their scope of practice to include other diseases of the lung and next by the assimilation of critical care medicine. Finally, the overlap of sleep medicine with pulmonary medicine has expanded the scope of practice again. Most training programs in the United States now identify themselves as departments (or divisions, or sections) of pulmonary, critical care, and sleep medicine. Each of these areas has structured and standardized curricula, training pathways, assessments, and certification processes, but together they define the subspecialty.

The process of transforming pulmonary medicine in China into a broader subspecialty of pulmonary and critical care medicine has already begun. The Chinese Society of Respiratory Diseases renamed itself the Chinese Thoracic Society. About 50 Chinese hospitals now identify their departments as “pulmonary and critical care medicine,” but common training pathways and ICU staffing and organization are only starting to be developed. The clinical and governmental leadership of China is committed to advance the field accordingly and decided to collaborate with ACCP because of its focus and expertise in educating pulmonary and critical care clinicians to formally launch fellowship training in pulmonary and critical care medicine in selected hospitals and, ultimately, nationwide.

A group representing the Chinese Thoracic Society and the ACCP is working actively to that end, collaborating to catalyze the development of PCCM as a distinct subspecialty of internal medicine in China, to establish medical and respiratory care units under the purview of departments of pulmonary and critical care medicine, and, perhaps most importantly, to design and ultimately introduce standardized and rigorous PCCM training programs across China. This ambitious effort will include surveying the current status of ICUs, staffing, and organization. The group will design and implement curricula and evaluation tools for trainees and faculty alike, professional development programs, and ultimately a formal Chinese subspecialty certification. Chinese PCCM physicians will serve as the voice of the new subspecialty to hospitals, medical societies, and the government; the outcome of this collaboration will be historic, as it heralds the recognition of a new subspecialty, with the first national fellowship training pathway in any medical specialty in China.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

CCM

critical care medicine

PCCM

pulmonary and critical care medicine

Wang C, Xiao F, Qiao R, Shen YH. Respiratory medicine in China: progress, challenges, and opportunities. Chest. 2013;143(6):1766-1773. [CrossRef] [PubMed]
 
Wang C. Respiratory physicians should assume take up the responsibility in the development of critical care medicine in China. Chin J TB Respir Dis. 2000;23(7):389-390.
 
Yan J, Gong SJ, Yi YH. ICUs in Zhejiang Province. Current status and future expectations. Zhejiang Med. 2012;34(2):73-74.
 
Qiao R. The evolution of dual certification in pulmonary and critical care medicine in USA. Chin J TB Respir Med. 2013;36(2):139-141.
 
Qiao R, Factor P. The ICU system in USA. Chin J TB Respir Med. 2013;36(6):1-3.
 
Qiao R, Buckley J. Fellowship training of pulmonary and critical care medicine in USA. Chin J TB Respir Med. 2013;36(5):1-4.
 
Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: a report from the profession. Chest. 2004;125(4):1514-1517. [CrossRef] [PubMed]
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Current and projected workforce requirements for the care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Duke EM. Health Resources & Services Administration, U.S. Department of Health & Human Services. Report to Congress: the critical care workforce: a study of the supply and demand for critical care physicians. Requested by Senate Report 108-81, Senate Report 109-103, and House Report 109-143. http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed June 23, 2013.
 
Brotherton SE, Etzel SI. Graduate medical education, 2011-2012. JAMA. 2012;308(21):2264-2279. [CrossRef] [PubMed]
 
Lorin S, Heffner J, Carson S. Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training. Chest. 2005;127(2):630-636. [CrossRef] [PubMed]
 
Tobin MJ, Hines E Jr. Pulmonary and critical care medicine: a peculiarly American hybrid? Thorax. 1999;54(4):286-287. [CrossRef] [PubMed]
 

Figures

Tables

References

Wang C, Xiao F, Qiao R, Shen YH. Respiratory medicine in China: progress, challenges, and opportunities. Chest. 2013;143(6):1766-1773. [CrossRef] [PubMed]
 
Wang C. Respiratory physicians should assume take up the responsibility in the development of critical care medicine in China. Chin J TB Respir Dis. 2000;23(7):389-390.
 
Yan J, Gong SJ, Yi YH. ICUs in Zhejiang Province. Current status and future expectations. Zhejiang Med. 2012;34(2):73-74.
 
Qiao R. The evolution of dual certification in pulmonary and critical care medicine in USA. Chin J TB Respir Med. 2013;36(2):139-141.
 
Qiao R, Factor P. The ICU system in USA. Chin J TB Respir Med. 2013;36(6):1-3.
 
Qiao R, Buckley J. Fellowship training of pulmonary and critical care medicine in USA. Chin J TB Respir Med. 2013;36(5):1-4.
 
Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: a report from the profession. Chest. 2004;125(4):1514-1517. [CrossRef] [PubMed]
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Current and projected workforce requirements for the care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Duke EM. Health Resources & Services Administration, U.S. Department of Health & Human Services. Report to Congress: the critical care workforce: a study of the supply and demand for critical care physicians. Requested by Senate Report 108-81, Senate Report 109-103, and House Report 109-143. http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed June 23, 2013.
 
Brotherton SE, Etzel SI. Graduate medical education, 2011-2012. JAMA. 2012;308(21):2264-2279. [CrossRef] [PubMed]
 
Lorin S, Heffner J, Carson S. Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training. Chest. 2005;127(2):630-636. [CrossRef] [PubMed]
 
Tobin MJ, Hines E Jr. Pulmonary and critical care medicine: a peculiarly American hybrid? Thorax. 1999;54(4):286-287. [CrossRef] [PubMed]
 
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