Whilst other medical specialties deal exclusively with specific organs or body systems, ICM encompasses the entire spectrum of medical and surgical pathology.
An ICM doctor is able to provide advanced organ support during critical illness and is responsible for coordinating the care of patients on the ICU.
ICM is high tech, lifesaving care that underpins and interacts with all other areas of the hospital.
Below are career stories reflecting on various aspects of working in ICM
Is on-call possible at 60?
It is possible that 2015 will be recognised as a seminal year for the medical
workforce in ICM and all other specialties. At the time of writing, contract
negotiations that may change terms and conditions of working for a
generation of doctors (in England at least) are underway. Whether the
feasibility of being on-call during the later parts of a career will be
addressed as part of these discussions is not certain. What is clear,
however, is that ICM should not rely on external events and agencies to
solve what is an increasing concern for many in the specialty.
The changing demographic profile affects doctors as well as patients.
We’re all increasingly aware that the demographic of our patients is
changing. We provide intensive care to older patients than we did a decade
ago, and predictions suggest this trend will continue1,2. These patients
are complicated, have challenging co-morbidities, and need experienced
clinicians to manage them effectively. The Academy of Medical Royal
Colleges report into Seven-day Consultant Present Care3, outlines how
‘patients expect treatment by competent clinicians and a parity of care
irrespective of the day of the week’. The FICM / ICS Core Standards4
re-enforce the need for regular consultant input irrespective of the time or
day of the week.
We need to remember, however, that as doctors we are ageing too.
1 Sean M Bagshaw et al., “Very Old Patients Admitted to Intensive Care in
Australia and New Zealand: a Multi-Centre Cohort Analysis,” Critical Care
13, no. 2 (2009): R45, doi:10.1186/cc7768.
2 C BRANDBERG, H BLOMQVIST, and M JIRWE, “What Is the Importance of Age on
Treatment of the Elderly in the Intensive Care Unit?,” Acta Anaesthesiologica Scandinavica
57, no. 6 (February 4, 2013): 698–703, doi:10.1111/aas.12073.
3 AoMRC, “Seven Day Consultant Present Care,” Aomrc.org.Uk, accessed
November 29, 2015, http://www.aomrc.org.uk/doc_view/9532-sevenday-consultant-present-care.
4 Core Standards Working Party of the Joint Professional Standards Committee, “Core
Standards for Intensive Care Units” Ficm.Ac.Uk, n.d.
Changes to retirement age and pensions means that consultants will be
expected to work until their late sixties. We must ensure they are able to
do so effectively and safely. How?
‘Burnout’ is a big topic: a full discussion is out-with the remit of this article,
but it merits consideration in this context. Often associated with ICM, there
is little literature from the UK, although stress in UK intensivists has been
described5: burnout is more assumed than measured. A ‘real time’ survey
I conducted using voting pads at last year’s ‘State of the Art Meeting’
suggested that the audience (obviously a self-selected and highly
unscientific sample!) were very interested in the subject, but knew little
about it. They wrongly believed that burnout is most likely in older, male
colleagues (it isn’t - young, female doctors are the most affected group6)
and failed to recognise the impact that conflicts can have7, feeling that
organizational issues (such as bed shortages) were more likely to
precipitate the problem.
Alternative Ways of Working
A central tenant of medical rotas has often been ‘equality of burden’: that
all contribute their share of the work – often translated by rota-masters
into a division of nights, weekends and bank holiday duties between those
on the rota.
Is this the only way to work ‘fairly’? Increasingly units have different
arrangements for colleagues with particular requirements. I have a
colleague with university commitments who works ‘excess’ weekends to
make time available for university duties during the week, a solution
readily accepted as both necessary and ‘fair’ by others on the same rota.
Shouldn’t we accept that alternative working patterns may be necessary
5 S Coomber, “Stress in UK Intensive Care Unit Doctors,” British Journal of Anaesthesia 89,
no. 6 (December 1, 2002): 873–81, doi:10.1093/bja/aef273.
7 E Azoulay et al., “Prevalence and Factors of Intensive Care Unit Conflicts: the Conflicus
Study,” American Journal of Respiratory and Critical Care Medicine 180, no. 9 (October 20,
2009): 853–60, doi:10.1164/rccm.200810-1614OC.
for other demands, such as an ageing workforce?
Other colleges are exploring similar issues. The RCEM is acutely aware of
the need to keep consultants engaged and working, and suggests the
development of annualised job plans can help to ‘embed safe and
sustainable practice’8 . Similarly, the RCPCH report into New ways of
working describes how the use of resident consultant on-call and ‘twilight
shifts’ can help to solve rota problems, and describes how consultants may
transition through different out of hours’ commitments depending on the
stage of their career. That the same report suggests its findings are
applicable to other 24/7 specialties, and suggests future collaboration to
develop future service models, should make us take notice.
So is on call possible at 60? I’m not sure, but its definitely not the only way
to work. We need to explore different ways of working :changing working
patterns and developing annualised job plans to mitigate the increasing
demands on an ageing workforce. Improving awareness of factors
associated with burnout may allow intensivists to better protect
themselves and avoid this problem - either early or later in their career.
As a specialty it is definitely something we need to think about. After all,
these are our careers we’re talking about!
Careers Lead, FICM
8 RCEM, “Developing Annualised Rotas for Emergency Medicine Consultants,”
September 23, 2013.
Dr V Jagannathan – Consultant in Intensive care medicine and Anaesthesia with special interest in Obstetric critical care
I have been very lucky as a young consultant to not only pursue my choice of career in medicine but also my chosen specialty. For this, I am deeply indebted to my trainers who took the time to support and lead me.
I joined medicine through a competitive process in India when I was 16 years old and never looked back. Critical care was what I always wanted to do – it amalgamates a multitude of skills, cutting across various medical specialties and challenges oneself to perform and serve.
I came to the United Kingdom to train in Intensive care in early 2002 – at a point when such training was not formally available in India and in early developmental stages in England. I joined as a clinical observer in ICM in London and then went to Aberdeen as a SHO in ICM and then anaesthetics. My training journey was complicated (due to both personal and professional reasons). I trained in London and the North east of England, completing my training in 2012 with dedicated time in intensive care (advanced training) and obstetric anaesthesia (higher module).
Working in a challenging specialty such as intensive care helps one develop personal resilience, and the long duration of training, such as mine, mirrors the training pathways of many others. Long working hours, dysfunctional work-life balance, exams, rotas and working with staff shortages are all synonymous with the training.
However, for all aspiring intensivist out there, all this toil is repaid in kind from all the happiness and expressions of gratitude from the sick patients and their family we serve. It reminds us ultimately why we are in this profession.
I am now a consultant in intensive care at a big district general hospital in the North of England. I balance my day to day life as an intensivist with a lovely family with two children. My work life is busy, I have an interest in dealing with sick parturient, contribute as an ICM assessor for MBBRACE, have management interests (I have been the Lead for a 16 bedded unit for last 3 years) and have been part of a Faculty committee for the last 2 years.
Intensive care skills give you the choice to train others, gain management skills and be at the fore of change in such a critical time for the NHS – being the only common denominator specialty amongst all intra-hospital care of patients.
A Day in the Life of an Intensivist Intensivists are part of a large specialist team that provide care for the sickest patients in the hospital in a complex, dynamic environment. The successful intensive care physician requires a sound understanding of basic sciences and medicine, diagnostic acumen, proficiency in a number of invasive procedures and a broad range of non-technical skills.
Referrals to critical care may come from anywhere in the hospital. As an intensivist, you may be called to review a deteriorating patient with sepsis on the medical ward who needs respiratory and circulatory support, to resuscitate a polytrauma patient in the emergency department, or to assess a shocked patient following surgery. The diverse nature of critically ill patients means that one of the rewarding aspects of being an intensivist is delivering patient care in collaboration with colleagues from across the entire spectrum of medical specialities - often with several at the same time. Although our patients are the sickest in the hospital and may present with a myriad of diagnostic and management challenges, it is focusing on providing safe and high quality basic care that is the bedrock of a successful ITU.
The day of the intensivist often has a familiar structure - but there are few places in the hospital where the adage every day is different is more apt. The morning multidisciplinary handover is a forum to review all recent imaging, blood results and investigations, and allows for a detailed update and discussion of each patients progress. A safety briefing helps determine any potential hazards and the relevant activity expected both on the unit and in the wider hospital for the day, as well as highlighting if there are patients suitable for trial inclusion, or any complex or long term patients requiring discharge plans. A thorough clinical ward round forms the foundation of decision-making and planning of daily goals for each patient as well as a good opportunity for teaching.
The ITU is an ideal place to develop and use innovative monitoring and therapeutic technologies, and provides an environment to develop skills with echocardiography and ultrasound, as these modalities increasingly change the management of critically ill patients. Common procedures that require proficiency on ITU include invasive line insertion (including catheters for renal replacement therapy or cardiac output monitoring to guide inotropic, vasopressor and fluid therapy), bronchoscopy, chest drain insertion and percutaneous tracheostomy.
Intensive care medicine has a range of sub-specialties, and offers the opportunity to develop specialist skills in areas such as neurointensive care, burns, paediatric and cardiothoracic intensive care. Important areas outside the ITU where the intensive care team are also integral to patient care include outreach and critical illness rehabilitation.
Discussing and delivering end of life care are some of the most challenging and rewarding skills for the intensive care doctor to develop, and these skills are continually developed throughout one’s career. Other non-technical skills such as ethically sound, non-biased decision-making, and communicating clearly and empathically with patients and relatives are of paramount importance.
Intensive care medicine is constantly expanding and evolving as a specialty. It offers the specialist doctor a chance to develop a unique set of skills in an exciting and dynamic setting - in which it is difficult to be bored!
A Day in the Life of an Intensivist-Working in the South West
Where I work
I work in a progressive 600 bedded District General Hospital in Somerset, where I am one of a team of 8 intensivists that look after a 12 bedded critical care unit.
Why I work here
District General Hospitals offer a unique blend of quality of life and long term professional satisfaction for intensivists. ICM job plans in my trust are focussed on ensuring continuity of care and providing a sustainable work life balance. One consultant is nominally in charge of the unit from Monday - Thursday, and another covers Friday - Sunday, handing over Monday morning. A second consultant also covers the unit weekday mornings, to help with rounding, decision-making and referrals. Tuesday, Wednesday, and Friday nights are covered by other consultants not on for the week.
The patient case mix is fairly equally split between surgical and medical admissions which offers a broad spectrum of clinical presentations. For the majority of the consultant group, clinical time is split approximately 60:40 between ICM and other clinical commitments (such as anaesthesia) on a 10 PA job plan. This balance is adjustable as long as the ITU rota is covered, so people drop anaesthetic sessions if they wish to reduce their PAs. The intensivists are a cohesive group. We try to be flexible and accommodating to each other as this will of course work reciprocally in our favour.
One of the obvious attractions of working in a DGH is that it encourages close professional relationships with colleagues from other specialties. It is hard to walk down the main hospital corridor or grab a coffee without stopping to talk to someone, and I believe this degree of close and easy communication with both medical and nursing staff makes a significant difference to patient outcomes, as well as maintaining personal wellbeing.
The impact on family and professional life
Another significant reason I chose to work in a DGH was the opportunity to live and bring up my children in the countryside. I live on a farm and despite year round hard work this has a hugely positive impact on my work/life balance. Like a good number of intensivists physical exercise is important to me, and whenever I am able I cycle to work through an Area of Outstanding Natural Beauty.
Regardless of where one works there is always the opportunity to pursue other challenges outside the clinical sphere; amongst my other commitments I sit on a national FICM committee, examine for the FICM Final and contribute to patient care and the strategic direction of my Trust as a Clinical Director.
A Day in the Life of an Intensivist at Raigmore Hospital, NHS Highland: a remote and rural hospital.
Where I work
Raigmore Hospital, Inverness, is the main Hospital for the NHS Highland Health Board area and has 460 in-patient beds. The region covers an area of 15,000 square miles, which represents approximately 41% of the Scottish and 11% of the UK land surface (an area the size of Belgium). The area is highlighted in blue on the map and it also provides certain services to the Western Isles Health Board (Outer Hebrides) – the total population covered being 320,000. The catchment area comprises the largest and most sparsely populated part of the UK with all the attendant issues of a difficult terrain, rugged coastline, populated islands and a limited internal transport and communications infrastructure. The area is recognised for its outstanding natural beauty and access to all sorts of recreational activities such as road and mountain biking, sailing, hiking, climbing, fishing, snow sports and all kinds of water sports. The famous North Coast 500, 'Scotland's Route 66' has been named one of the top coastal road trips in the world is a major tourist attraction. The Scottish Highlands are fantastic place to live and bring up a family and provides a great work-life balance.
Critical Care Services
The current intensive care unit is equipped to take 7 Level-3 critically ill patients and has around 450 admissions each year. There is a separate 6-bedded surgical HDU and an 8-bedded Medical HDU. All the critical care units have nearly completed a major refurbishment and upgrade and, in May 2018, the ICU and Surgical HDU co-located to a completely new unit that is adjacent to the main theatre complex. This exciting development provides fully updated facilities and equipment. The combined unit has 16 beds – nominally 8 level-3 ICU beds and 8 surgical HDU beds, but works flexibly. The case mix of admissions is very variable – there are frequent polytrauma cases ranging from climbing accidents in the Cairngorms to motorcycle accidents on the rural single track roads. Patients that require cardiac or Map of NHS Highland INVERNESS neurosurgical intervention are transferred to Aberdeen which is about 2.5 hrs away by road ambulance. There are about 12-15 paediatric admissions/ year and the majority of these are retrieved from PICU teams (ScotSTAR), but due to the distance that has to be travelled, and also the challenging weather conditions, this can sometimes take longer than would be the case in other parts of the UK. The elective surgical workload that is on-site covers predominantly vascular, lower and upper general surgery, including liver resections and oesophageal/gastric resections, and major urology. The emergency surgical and medical admissions are varied as well and are probably similar to hospitals of a similar size.
How we work
There are 8 consultants who have daytime sessions on the ICU and the on-call is dedicated to intensive care and shared between us. We are a happy and cohesive team and frequently meet to discuss various issues. We have formal time set aside for consultant, clinical governance and audit, and general MDT/departmental meetings. Key departmental roles have been allocated within the group and we have been encouraged to develop various trust, regional, and national roles. Our working patterns have been specifically designed to give a sustainable and healthy working pattern for members of staff whilst at the same time aiming for the best quality and continuity in patient care. A ‘consultant of the week’ covers the days on the ICU from 0800 -1800 hrs Monday to Friday and is then on-call for 24 hrs on the Saturday. The weekends are ‘split’ – another consultant will cover the Friday night and the 24 hrs on the Sunday. The week following an ICU week is a ‘Zero-hours’ week when we are not expected to be in the hospital at all - this is a great way to catch up with some family time and means that we can actually enjoy the beautiful area that we live in. The remaining 6 weeks of the rota cycle are spent delivering anaesthesia in theatre (but could equally be another speciality), the share of the ICU midweek night-time on-calls, and other supporting professional activities.
Why might someone work in this environment
A number of the consultants working on the ICU have moved from other regions of the UK, and we are all very happy with the move. There are great colleagues, both medical and in the whole multidisciplinary team, we have an interesting and varied job with great potential for development, and we live in a fantastic part of the UK with outdoor opportunities second to none! Finally, I have written this article as I am a member of the FICMCRW committee – this is made possible as Inverness has excellent transport links – there are daily flights to London, amongst other destinations, and the flights get in early enough to make all the meetings in London.