What should distinguish our specialty from other medical specialties whose main goal is the management of critically ill patients (or at risk of being critically ill patients) are our values that can be summarized into these:

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  Competences (knowledge, skills and abilities): based on our teaching and continuous medical education (CME) team and supported by SEMICYUC Task Forces in collaboration with the Spanish Society of Intensive Nursing and Coronary Units (SEEIUC).

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  Availability and opportunity: anytime, anywhere.5,6

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  Diversity: possibility to handle all medical or surgical conditions in critically ill patients within the global management of patients.

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  Quality in all dimensions: always patient-based effectiveness, efficiency, safety and opportunity. We provide quality and we wish to evaluate the quality we provide for quality-planning purposes.7,8

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  Proactivity: both during healthcare and in keeping our values. Capacity to drive new healthcare processes.

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  Leadership: the 360° view of the patient allows us to condition and match the efforts of our healthcare providers with the efforts of other specialists in the decision-making process for the benefit of critically ill patients.9

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  Team work: there are too many of us taking care of the patients, which is why we have to team work in a multidisciplinary way.10

The implementation of these values is complementary meaning that no value can be implemented isolated from the others.

Each hospital and each CCU is different. Each place requires unique solutions based on the service portfolio and patient population of each hospital where balancing the different competences has been the standard practice to date and conditioned the present time. We believe that positioning ourselves against unqualified practices from other medical specialties should be approached from three different levels.

We need to inform state and autonomous administrations of how important our values really are and distinguish our specialty from other medical specialties. We need to let the Spanish ministries know about how core subjects can influence our residents’ training and ultimately how interrelated our medical specialty is with other medical specialties with which we can build alliances or disagree. The limits and functions of our specialty can be explained at this level, which is why we should take an active role in the process of change when it comes to new models of teaching medical specialties whether through core subjects or any other way. Without a doubt, it is the representatives of our scientific societies (SEMICYUC and GTPOG) who should represent the interests of our medical specialty and guarantee the existence of specialists with enough competences to assist the critically ill patient in the best possible way.

Also, we need to explain our competitive values to all autonomous communities. Health districts have the authority to make decisions such as create new ICUs without the presence of intensivists; define common health policies for the entire network of hospitals that will in turn set the limits of one medical specialty with respect to another and accredit and designate the name that the units that take care of critically ill patients will have. Both the autonomous societies and the local directors of our units should raise their voices before these health districts in a proactive and non-reactive way. We need to put on the table issues such as the availability of intensivists, their knowledge and our competence to conduct other activities that adapt our service portfolio to the actual needs of each hospital.

Scientific societies, in our case SEMICYUC, are created to promote and put in the map the medical specialty and associates it endorses. Therefore, they play an essential role in several aspects such as the following:

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  Look for legal support to outline the specialists’ fields of action and spread the news among its associates.

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  Tell the citizenship what the core of the specialty really is through informative campaigns, explain the reach of our medical specialty and that there are no ICUs without Intensive Care Medicine.

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  Look for alliances among the scientific societies of other medical specialties.

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  Advocate for the model of Intensive Care Medicine before the Spanish Ministry of Health, Social Services and Equality (MSSSI) and the corresponding health districts of all autonomous communities. Such a model proposes new service portfolios where the intensivists’ role will be key at the hospitals.

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  Open up a process of reflection on the possibility of accrediting ICUs to distinguish them from other units that may have a similar name to other medical specialties. Then only accredited units will be endorsed and these criteria will need to be promoted and implemented by the corresponding authorities of the autonomous communities (e.g. the specific legislation in force in the Autonomous Community of Madrid).11

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  Brief the MSSSI General Directorate of Professional Ordinance on the specialists’ concerns on issues regarding overlapping specialties such as sedation; strokes; coronary patients; patients receiving non-invasive mechanical ventilation; etc.

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  Promote efficient studies conducted by experts in the political economy of health that show the cost of healthcare models such as critically and semi-critically ill patient units not ran by intensivists.

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  Promote that health districts and hospitals conduct comparison studies evaluating the impact that different healthcare models have on healthcare quality (in terms of safety, effectiveness, and efficiency).

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  Promote the training and CME of the scientific society associates in areas of innovative competences that guarantee CME programs that are consistent with new technologies while implementing updated educational tools.

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  Develop registries to evaluate the outcomes and strategic planning.

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  Promote high quality research through Task Forces in an effort to develop multicenter studies and search for clinical trial funding through public and private competitive bids.

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  Reach positioning through the active participation in international scientific societies – both European and non-European in an attempt to achieve strategic positioning and visibility.

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  Make public knowledge of Intensive Care Medicine within the academic plan of college degrees and certificate degrees in Health Sciences (as it is already the case with some Spanish universities) where the comprehensive healthcare of critically ill patients should be an optional subject of the curriculum.

It is obvious that none of the aforementioned will be effective if we do not accomplish the most important thing – leadership at the hospital level. The Intensive Care Medicine competence map should be adapted to the characteristics of each hospital. The capacity to take good care of critically ill patients is based on the level of competence and compromise and commitment in this medical specialty.

A wait-and-see attitude with the critically ill patient is not acceptable. Planning quality healthcare can only happen if we have a global view of the patient and the opportunity to be involved early in the decision-making process and not wait for someone to give us a call. Therefore, we need to increase our service portfolio, look for and assist patients wherever they may be and detect those who may be at risk of getting worse. That is why leaders and service directors need to be leading this model change, their colleagues and, above all, the hospital management and representatives of the autonomous communities. CCUs need to proactively match the needs of the healthcare organizations they belong to by looking for solutions when the healthcare pressure is high using planned strategies that bring the right answer to timely demands by assisting patients outside our own units or avoiding cancelling scheduled surgeries.12

CCUs need to evolve outside the ICU setting. In many countries, Spain included, there are rapid response teams (RRT) consisting of one physician and one nurse who provide urgent care to all patients with acute events who require high-resolution consultations.13 This opens up the healthcare provided in Intensive Care Medicine to hospital patients too, which is a considerable change of mindset. These patients may never see the inside of an ICU but will surely benefit from our care and capacity to detect patients at risk of getting worse. The intensivist can and should treat critically ill or potentially critically ill patients outside the physical restrictions of the ICU. We should be providing the patients, the families, and the healthcare providers with open units and implement humanization plans that have already proven necessary following the impact and benefit they have had on the final outcome.14

The experiences of those CCUs that have already changed their service portfolio towards ICUs without walls or extended intensive care services (EICS) teach us that hospitals value this new approach15–20 which, on the one hand, gives us more control over the patients that will eventually be admitted to ICUs or intermediate care units and, on the other hand, makes us indispensable for the hospital management avoiding or minimizing the temptation to create other units. Therefore, we advocate for extending the scope of CCUs towards the hospital so that our healthcare can reach out to those patients who remain outside the ICU setting both prior to admission and after the patient has been discharged from the ICU.

The perspective we should take here is that RRTs are some sort of link between the ICU and the hospital floors by minimizing the healthcare imbalance that may occur when the patient is transferred from the thorough care provided at the ICU to the less intensive care provided at the hospital floor. This is another aspect we should take into consideration since it provides a new window of opportunity for intensivists to take action at the hospital setting and outside the ICU.

At local level, we can also develop other activities to increase our service portfolio. Sedation outside the ICU setting for short invasive procedures should not be at the center of Intensive Care Medicine, but instead conducted by intensivists in hospitals when needed. There is no legislation that prohibits it, since all physicians are responsible for their own acts regardless of their medical specialty and there is enough legal evidence backing this up. There is no question that we are fully capable of conducting short sedations while keeping all the values aforementioned. These patients should not be less important to us than the most complex ones. If we do it, we must do it right.

Circumstances and political decisions have limited the scope of our healthcare to potentially critically ill patients such as acute cardiac patients, those who suffer strokes, patients who require pacemakers, those who receive non-invasive mechanical ventilation, etc. At local level, we should understand that integration and non-dispersion in multiple units is more cost-effective. Also, at the hospital level, we should be aiming at other opportunities such as post-ICU syndrome consultations – of which we already have one experience in our country that has awaken the interest of health authorities21; parenteral nutrition in hospital floors; counselling on palliative care; need for a highly qualified technology (ECMO, MARS); cancer patients care, etc. We should encourage team work inside ICUs and CCUs not only looking to improve quality but also to engage all healthcare providers and reduce professional burnout rates.22

These plans should be implemented every day and all intensivists should be engaged here at all time assuming that it won’t always be easy to implement them and that there are no magical recipes for each center. Only when we understand that advocating for our medical specialty means we must all accept and play our own role we will be able to give younger residents and assistant physicians the future we all want to see that they also demand. Management guidelines say that our attitude should be based on three words: insistence, persistence and resistance. Let's go for it.

The authors declare no conflicts of interest whatsoever while preparing and writing this manuscript.