The Chairperson of the Task Force (P.E.P.) worked with leadership from the ABIM, ACCP, APCCMPD, ATS, and SCCM to identify and include a group of participants with diverse interests in clinical medicine, education, and research, but who were all involved in training fellows in one or both of these disciplines.

In December of 2006, a member of the Task Force (J.D.B.) collated into one document the lists of existing competencies from the websites of the ACGME (Pulmonary/Critical Care Medicine Program Requirements) (6), Harmonized Education in Respiratory Medicine for European Specialists (HERMES) (7), Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) (8), the ABIM (Subspecialty in Pulmonary/Critical Care Medicine) (9), and the Alliance for Academic Internal Medicine (AAIM) Education Redesign Task Force draft documents for the “Core” of Internal Medicine (10). Many of the competencies identified by these groups were similar if not identical. Task Force members were encouraged to list additional competencies during several brainstorming sessions. In a systematic manner using a modified Delphi approach (11), each specific competency was categorized into one of the six core competency headings outlined by the ACGME. These core competencies are:

1. Communication and Interpersonal Skills

2. Medical Knowledge

3. Patient Care

4. Practice-based Learning and Improvement

5. Professionalism

6. Systems-based Practice

The Task Force worked via conference calls, e-mail exchanges, and in person on multiple occasions during 2007 and 2008. While developing this document, the Task Force considered the unintended consequences of these recommendations including their use by credentialing and certifying organizations that could impact current training program requirements, maintenance of certification, medical licensing, and hospital credentialing.

There was early emphasis on acknowledging that the competencies in Pulmonary Medicine and Critical Care Medicine overlapped, but that there were distinct differences. With approximately 90% of Critical Care physicians in the United States having backgrounds in Internal Medicine (12), the Task Force focused on Internal Medicine-based Critical Care Medicine. Future efforts will identify explicit commonalities and differences that may exist between Critical Care Medicine physicians and those Critical Care physicians who enter practice from training pathways in Surgery and Anesthesiology.

The initial compilation from the process outlined above was used as a starting point for developing a final, multisociety summary of specific competencies for both Critical Care Medicine and Pulmonary Medicine. Modifications, additions, and deletions were conducted using several techniques:

1. Individual member review of each item in the initial compilation;

2. Brainstorming at in-person meetings and by conference call;

3. Nominal group methods for most items to retain the view and opinions of the minority perspective;

4. Whole group discussions and voting on controversial dichotomous issues with decisions determined by a simple majority vote;

5. Iterative, modified Delphi techniques including distribution of the competencies a minimum of three times to achieve consensus on the final list of competencies.

• 0: No additional knowledge and experience beyond that obtained in Internal Medicine training OR not relevant to the discipline being considered (Critical Care Medicine or Pulmonary Medicine).

• 1: Knowledge/behavior/procedural skill relevant to the practice of the discipline but primary expertise/proficiency is within the purview of another specialty such that consultation or further in-depth literature review is typically required;

• 2: Knowledge/behavior/procedural skill fundamental to the practice of the discipline. Expertise/proficiency in this area is expected.

Finally, the competencies and scoring were distributed to the executive leadership of the ACCP, APCCMPD, ATS, and SCCM for review and feedback. This step served to obtain official approval from each organization and was a final step in validation of the results of the Task Force results.

During the scoring of the individual competencies it became clear that there is a difference in the philosophy of individual training programs with regard to the required clinical experiences. This is most evident in the “nonmedical” aspects of critical care that are generally outside the purview of Intensivists from Internal Medicine backgrounds, such as the evaluation and management of abdominal compartment syndrome, intracranial hemorrhage, and increased intracranial pressure. Although some members of the committee considered these to be core knowledge (assigned a score of two), others did not (score of one). The origin of these philosophical differences may reside, in part, in the predominant patient population cared for by the Critical Care Medicine physician. Training programs based primarily in medical ICUs may perceive competencies differently than those based in multidisciplinary ICUs (i.e., combined Medical-Surgical ICUs).

Furthermore, several competencies reflect various discipline-specific perspectives of specific diseases. For example, a Pulmonary perspective of asthma may require competency in understanding the mechanisms and pathophysiology of asthma, but a Critical Care Medicine perspective may require a competency in understanding the physiology and management of respiratory failure caused by asthma. Another example would be the diagnosis and management of severe exacerbations of systemic lupus erythematosis (SLE). Whereas the perspectives and competencies for Rheumatology and Critical Care Medicine specialists will differ for SLE, these differences may be appropriate.

Where possible, the competencies were developed side-by-side with the perspective of other disciplines. For example, in deep-water diving injuries, a pulmonary specialist would be expected to screen subjects appropriately and to conduct a risk assessment, but a Critical Care Medicine specialist would be expected to manage the acute illness. Of course, many individual physicians may have training, experience, and competency in both.

Leadership in Critical Care Medicine and in Pulmonary Medicine encompasses a broad array of clinical experts, credentialing and certifying organizations, and specialty societies. This multisociety Task Force is an initial, collaborative attempt to identify current, specific competencies in Critical Care Medicine and Pulmonary Medicine in tandem. Since this document was first developed, we have recognized that several items may need to be added, modified, or deleted, underscoring the need for continuous review and revision that reflects the ongoing acquisition of medical knowledge, changing clinical practice, and working knowledge of how to deliver the best possible care to patients.

Defining specific competencies is necessary to ensure effective training of clinicians. As medical schools and residencies outline their own specific competencies, we must coordinate our efforts in developing an efficient continuum of education that transcends formal training. This document represents a consensus recommendation of current, fundamental Critical Care Medicine and Pulmonary Medicine competencies. It is a starting point that will guide future educational goals and professional development. Consensus on the competencies sets the stage for other activities essential to educational development, including:

• Creation of curricula for specific competencies;

• Validating assessment methods;

• Identifying unique milestones for each competency that must be met before moving from one phase of education to another (i.e., medical student, to resident, to fellow, to independent practitioner);

• Nurturing an individual's self-reflection in a continuous manner that fosters the cycle of experience, reflection, conceptualization, and further practice (13).

Many challenges remain, including faculty development, identifying and supporting dedicated teachers and program directors, and the need for additional valid methods of competency assessment. In an era of increasing financial uncertainty of the support for medical education, the consolidation of efforts and resources has the best chance for success. We already have strong agreement between the ACGME and ABMS on definitions of the core competencies (1). Engagement of all key stakeholders across the spectrum of training levels and medical societies is essential to facilitating a cohesive, effective mechanism for advancing the medical profession.

This Task Force's members and supporting societies hope that projects like this will continue to support collaborative interactions as the fields of Critical Care Medicine and Pulmonary Medicine evolve. Each discipline will evolve independently and also in conjunction with the other. Continued collaboration could result in a centralized review process for determining the relevance and priority of specific competencies, coordinating the development of teaching methods, researching assessment techniques, and identifying milestones. In contrast to a network of silos, a multisociety effort is more likely to help our profession move forward and integrate with credentialing and certifying organizations, residency and fellowship training programs, and medical schools.