Who is an intensivist? Doctors demand Apex Medical Regulator to re-evaluate the criteria
New Delhi: Upset with the definition of an 'Intensivist' provided by the Directorate General of Health Services, doctors working as critical care specialists recently approached the National Medical Commission (NMC) and urged the Commission to intervene.
In the recently released guidelines for Intensive Care Unit Admission and Discharge Criteria, apart from recognising doctors with NMC-recognised super speciality degrees, DGHS had mentioned that a few candidates of the Indian Society of Critical Care Medicine (ISCCM) Certificate Course- Certificate of Training in Critical Care Medicine (CTCCM) who have been certified with a 3-year training programme in the Intensive Care after MBBS are also recognised as Intensivists.
Upset with this definition provided by the DGHS, the critical care specialists who have pursued the NMC-recognised PG medical courses, recently approached the Apex Medical Commission and expressed their concern regarding the matter.
The issue was also raised by the Federation of Resident Doctors Association (FORDA), which wrote to the NMC secretary and requested its intervention to review and refine the criteria and emphasize the significance of NMC-recognized qualifications for the designation of super specialists in various medical disciplines.
In this regard, the doctors, including the representatives from FORDA, met the NMC Secretary Dr B Srinivas on 08.03.2024 and the meeting concluded with a consensus to proceed with the exclusive recognition of NMC-approved courses, at the same time acknowledging the confusion that has been borne as a result of DGHS guideline.
During the meeting, it was decided that a meeting would be arranged under the leadership of the authority at the Union Health Ministry to discuss the matter. Besides, a meeting would also be held with the National Board of Examinations (NBE) to discuss the issue of running a non-NMC diploma/fellowship along with DrNB CCM.
Commenting on the matter, one of the specialist doctors working as a consultant in critical care told Medical Dialogues, "There are gross differences between society (ISCCM's Course) and curriculum-run courses. What is the point of super speciality courses if working for 3 years after obtaining the MBBS degree earns a doctor the same recognition? Shortcuts should not be promoted by the Government."
Who is an Intensivist as per DGHS?
Medical Dialogues had earlier reported that last year releasing the guidelines for Intensive Care Unit Admission and Discharge Criteria, DGHS, operative under the Union Health Ministry offered a clear-cut definition of who is an "Intensivist" or Critical Care Specialist.
These guidelines, compiled by a total number of 24 experts and released by the Directorate General of Health Services (DGHS) operative under the Union Health Ministry, specified that to be called an "Intensivist", a specialist needs to have a specific training, certification and experience in managing critically ill patients in an ICU.
As per the guidelines, the Intensivist should have a postgraduate qualification in Internal Medicine, Anaesthesia, Pulmonary Medicine, Emergency Medicine or General Surgery with either of the following:
a) An additional qualification in Intensive Care such as DM Critical Care/Pulmonary Critical Care, DNB/FNB Critical Care (National Board of Examinations), Certificate Courses in Critical Care of the ISCCM (IDCCM and IFCCM), Post-Doctoral Fellowship in critical Care (PDCC/Fellowship) from an NMC recognised University, or equivalent qualifications from abroad such as the American Board Certification, Australian or New Zealand Fellowship (FANZCA or FFICANZCA), UK (CCT dual recognition), or equivalent from Canada
b) At least one-year training in a reputed ICU abroad.
Apart from this, the guidelines clarified that a few candidates of the ISCCM Certificate Course (CTCCM) who have been certified with a 3-year training programme in the Intensive Care after MBBS are also recognised as Intensivists. "In addition, persons so qualified or trained must have at least two-years’ experience in ICU (at least 50% time spent in the ICU)," stated the Guidelines.
If a doctor does not have either of the above-mentioned qualifications or training, they are required to have extensive experience in Intensive Care in India after MBBS, quantified as at least three years' experience in the ICU (at least 50% time spent in the ICU).
Doctors Upset with DGHS's Definition:
Upset with the definition provided by the DGHS to identify an "Intensivist", the doctors, working as critical care specialists recently wrote to NMC and expressed their grievances and concerns over the "misleading" definition of the term prescribed by the Union Health Ministry.
While the doctors expressed their appreciation for the efforts to establish standards for managing critically ill patients in the ICUs, they expressed their concern regarding the inclusion of doctors who completed a three-year training program in ICU after MBBS without pursuing a recognized specialty course.
"The notification, as currently outlined, includes individuals who have pursued postgraduate qualifications in Internal Medicine, Anaesthesia, Pulmonary Medicine, Emergency Medicine, or General Surgery, with an emphasis on additional qualifications in Intensive Care. While we acknowledge the importance of specialized training, our primary concern lies with the inclusion of doctors who have completed a three-year training program in Intensive Care after MBBS without pursuing a recognized specialty course," the critical care specialists mentioned in their letter addressed to the Commission.
"In the era of NEET, where a rigorous six-year course duration is typically required to attain super-specialization in India, we find it challenging to equate the comprehensive training undertaken by doctors pursuing recognized specialties with those who have completed a shorter training duration after MBBS. We firmly believe that degrees recognized by the National Medical Commission (NMC) (reference R19022/08/2023/ethics/048032) should be the benchmark for due recognition, ensuring that only qualified specialists manage critically ill patients in ICUs," the letter added.
The doctors urged the NMC to reconsider the criteria to align more closely with the standards set by NMC and other international bodies. It opined that recognition as an "intensivist" should be reserved only for individuals with postgraduate superspecialty qualifications in Intensive Care, such as DM critical Care/DrNB/FNB Critical Care, or equivalent qualifications from recognized institutions.
"This approach ensures a uniform and high standard of expertise among intensivists, safeguarding the quality of critical care services in the country," the letter by the doctors mentioned.
While they acknowledged the importance of experience and appreciated the inclusion of candidates from ISCCM Certificate Course under the definition, they urged the Commission to reevaluate the criteria.
"We understand the importance of experience in the field, and we appreciate the acknowledgment of candidates from ISCCM Certificate Course (CTCCM) who have completed a 3-year training program in Intensive Care after MBBS. However, we urge a reevaluation of the criteria to maintain a balance that upholds the integrity of specialization while recognizing valuable experience," the letter mentioned.
"In conclusion, we request your kind intervention to review and refine the criteria, emphasizing the significance of NMC-recognized qualifications for the designation of intensivists in India. This step would not only uphold the standards of medical practice but also ensure the safety and well-being of critically ill patients under the care of qualified specialists," it added.
Representation from FORDA:
Raising the issue, the Federation of Resident Doctors' Association (FORDA) wrote to the NMC and expressed its concerns regarding the growing trend in recognizing super specializations in various medical disciplines.
The association referred to the current trend that includes individuals with postgraduate qualifications, often emphasizing additional qualifications in specialized areas. "However, we find it challenging to equate the comprehensive training undertaken by doctors pursuing recognized super specialties with those who have completed shorter training durations after MBBS," FORDA mentioned in the letter.
Referring to the present scenario where a rigorous 6-year course duration is typically required to attain super specialization in India, the association urged NMC and the Union Health Ministry to consider the potential impact on the opportunities for candidates pursuing six years of courses to become proper superspecialists.
Pointing out how this growing trend raises concerns across various medical disciplines, FORDA highlighted that in cardiology, numerous courses enable non-cardiologists to perform echocardiography, potentially substituting cardiologists.
"Similarly, in radiology, the proliferation of short-term ultrasound courses raises concerns about the comprehensive training required for diagnostic imaging. In critical care, certain courses allow doctors to be recognized as super specialists without pursuing recognized qualifications, potentially impacting the quality of care. Additionally, in pulmonary medicine, allied courses allow doctors to equate themselves as chest physicians, potentially compromising specialized care," it mentioned in the letter.
Expressing its "resentment" for the DGHS guidelines regarding ICU admission and discharge criteria, FORDA highlighted that while the purpose of the guideline has been addressed meticulously, "...the inclusion of all shorter duration courses under the same umbrella of NMC recognized courses is a dishonor to structured NMC programs and also to the hard work of candidates and aspirants pursuing superspeciality courses."
"We propose a reconsideration of the criteria to align more closely with the standards set by NMC and other international bodies. Recognition as a super specialist should be reserved for individuals with recognized postgraduate superspecialty qualifications, such as DM, DNB, FNB, or equivalent qualifications from recognized institutions. This approach ensures a uniform and high standard of expertise among super specialists, safeguarding the quality of medical services in the country," it added.
Urging the NMC to intervene and the association demanded a re-evaluation of the criteria to maintain a balance that upholds the integrity of super specialization while recognizing valuable experience. "This step would not only uphold the standards of medical practice but also ensure the safety and well-being of patients under the care of qualified super specialists," it opined.
