The national commission on medical specialties in Spain defines intensive care as the medical specialty that manages severely ill patients with one or more dysfunctional organs and at high risk of death or permanent disability, but with the possibility of a complete recovery7. Specialists in intensive care medicine often serve as general physicians for severely ill patients, who may have been referred or are primarily managed by a variety of other medical departments. Intensive care therefore represents a medical specialty that must maintain horizontal relationships with a variety of other specialties within a medical institution.

Intensive care medicine has existed as a primary medical specialty in Spain for approximately the past 35 years, as is the case in some countries in Latin America. In many other countries, however, including most of the rest of Europe, the United States and other parts of Latin America, training in intensive care medicine comprises secondary specialty education following primary training in internal medicine, anaesthesiology, surgery or emergency medicine.14,15 Parts of Western Europe, Africa and Southeast Asia are now initiating efforts to introduce and harmonise intensive care as a primary medical specialty. The international Competency Based Training programme in Intensive Care Medicine for Europe (CoBaTrICE; www.cobatrice.org) has identified key competencies that should be included as part of intensive care training and aims to serve as a basis for high-quality global training programmes, independent of the current system of training, to ensure a uniform standard of care.16–26

Unfortunately, the supply of physicians trained to provide intensive medical care has not kept pace with increasing demand, leaving many intensive care units (ICUs) understaffed with qualified personnel.13,27–29 Educational institutions and programmes need to implement measures to ensure that an adequate number of physicians are trained to provide intensive care to the population that may require these services.30–33 One potential strategy may be the exposure of medical students to intensive care departments at an early stage in the medical education curriculum, thereby increasing the chances that young physicians choose intensive care as a specialty.

Organisation within a medical institution may comprise so-called open ICUs that manage patients under the primary care of and physically located within other medical departments. In contrast, closed ICUs care for severely ill patients with a variety of medical indications under the primary care of intensive care physicians and physically located in a common facility with the necessary means, materials and expertise readily available. Key to the success of either model is the rapid detection and treatment of patients at risk of severe complications, thereby reducing or avoiding lengthy ICU stays.7,34–36

Another key component of optimal intensive patient care is the availability of a specialist trained in intensive care medicine at all times.37 Institutions with limited resources or located in remote areas may need to rely on consultation with trained specialists using virtual means, but ultimately an intensive care specialist should be available at every ICU bedside and at all hours of the day and night.7,27,38–44

After more than 60 years of research in intensive care medicine, notable progress has been made in areas such as ventilation and renal replacement, changing clinical practice and improving patient outcomes. In parallel, the necessary infrastructure has been created to support the execution of randomised controlled trials (RCTs) in the intensive care setting now and in the future.45,46 While more well-designed RCTs that provide clear clinical guidance are required, the adaptation of RCT results to real-life clinical scenarios remains a challenge, and innovations in research design may be necessary to ease this transition.47

One notable failure, after three decades of research, has been the search for a universal treatment solution for septic patients.48 Future efforts will need to focus on successful translational research to address this and other remaining clinical needs. Important will be the training and recruitment of young physicians with an interest in performing translational research. The European Board of Intensive Care Medicine has prepared a set of recommendations for modifications to the European Commission's Clinical Trials Directive (2001/20/EC) that aim to streamline both the costs and time required for new treatment or management concepts to reach the clinic (http://ebicm.esicm.org/eu-activities/clinical-trial-directive). Coordinated changes in the way in which intensive care research is regulated, for example the use of centralised institutional review boards to approve larger multi-centre trials, may also serve to improve efficiency.

Research of any kind requires financial resources, and a disproportionate amount of money is spent on patient care in the ICU relative to research to support advances in the field.49 With a history of disappointing results in some areas of intensive care medicine,50–52 the pharmaceutical industry may be increasingly hesitant to support large RCTs without some reassurance of a successful outcome. Therefore, the aim of translational research should be to identify areas in which an investment in large RCTs is likely to be worthwhile.11 In the meantime, professional societies with an interest in this area may need to play a larger role in supporting translational research studies.

Clinical research efforts in both oncology and haematology over the past two decades have been successful in part because participation in clinical trials has become a routine component of clinical management. To ensure further progress in intensive care medicine, physicians should aim to include every ICU patient in at least one clinical trial.

Future research will need to develop models that can accommodate both the clinical complexity and the multimodal interventions that are often required to treat critically ill patients. Electronic simulation of some conditions provides the opportunity to experiment with innovative treatment or management strategies without putting patients at risk. The use of biomarkers in the clinic is rapidly changing patient management in many areas of medicine and is likely to do so in the ICU setting, such as septic patients,53–57 as well.

The use of so-called electronic or tele-ICUs has gained in popularity, particularly in the United States, and is likely to continue to support patient care for units in remote areas, rapid response teams in the field and institutions that do not maintain around-the-clock intensive care staff.58–61 Institutions and countries with limited resources have also begun to develop means by which to perform collaborative research using electronic networks such as registry databases and surveys, which facilitate the collection and comparison of larger numbers of intensive care units and patients. This type of research will contribute to a global picture of ICU management and support efforts to establish a uniform standard of care. Collaborative projects between individual national or regional professional societies can also be enhanced using electronic networks.

The conflict between rising health care costs, the availability of complex medical procedures, increasing demand created by ageing populations and limited resources may require changes in the allocation as well as the management of health care. While extreme medical measures may be applied to any patient, independent of the cost or likely benefit, a rational balance must be achieved between the level of care that is possible and that which is appropriate to the individual situation. Such ethical considerations are delicate to approach, awkward to discuss and preferentially avoided by both individuals and policy makers. Unfortunately, intensive care patients, their families and medical caregivers are often confronted with end-of-life decisions that require a rapid consensus.

Some of the awkwardness and insecurity associated with health care decisions for critically ill patients could be alleviated by increasing awareness of the necessity for individuals to contemplate and discuss the options and consequences of intensive medical care and clearly document their preferences before the medical need arises.62 One consideration for both individuals and societies is the personal and economic costs compared to the likely benefits to be achieved by a particular intervention. Age, life situation, the type of likely disability to be expected and longer-term quality of life issues all factor into treatment decisions that look beyond simple mortality.

Because a large proportion of societal resources in many countries are spent on critical care medicine,13,63,64 physicians and institutions often find themselves faced with pressure to reduce costs by any means.65 Research advances in intensive care medicine reflect progress in medical care as a whole; therefore more, rather than less, investment to support innovation, increase efficiency and improve patient outcomes is needed and might well achieve the same economic goals in the long run.66 Unfortunately, the bodies that generally support research are not necessarily the same communities that may benefit if a patient can be fully rehabilitated, however, carefully designed health-economic research can lend support to these arguments by showing the relationships between the risk of mortality and morbidity, cost of care in the ICU, cost of long-term care if the patient survives with sequelae, negative cost if the patient is partially or fully rehabilitated and quality of life measures.39,67,68

Medical advances require the synergistic efforts of physicians, patients, regulatory bodies and industrial partners. Without economic incentives to develop new products and cooperation in bringing these products into clinical use, industrial interests may focus on other areas of medicine that present lower thresholds to be overcome.

While medical advances may ultimately reduce the direct and indirect costs of critical care medicine, structural changes may contribute more immediately to savings. By identifying patients likely to require intensive care and initiating treatment early, ICU stays may be shortened or avoided entirely.67–69 Particularly in countries or regions with limited resources, the definition of a minimum level of care that should be available to all who require it would provide the basis on which policy makers can base allocation of the resources that are available. Medicare, the health care reimbursement system for the elderly in the United States, plans to withhold reimbursement from hospitals that do not implement, assess and adhere to minimum quality standards.70 Government agencies and contributors of economic support could use similar tools to ensure the implementation of a minimum level of critical care.

One of the major functions of professional medical or scientific societies is to provide a link between physicians and the society at large, represented by its political bodies. Individual physicians are affiliated with institutional and national organisations, which can in turn cooperate with regional, continental and global organisations, the collaborative efforts of which are more likely to produce results at the level of public policy than individual smaller organisations. Aside from patient advocacy organisations, scientific societies also indirectly represent patient interests, thereby providing a voice for the patient community.

Scientific societies also serve as a structure within which physicians and industry can meet to exchange knowledge and research advances and ensure a standardised level of high-quality care. The Declaration of Vienna, generated by the European Society of Intensive Care Medicine (ESICM) and signed by a long list of national and international intensive care organisations, outlines the principles that should support patient safety and quality of care, including measures to avoid human error, optimisation of existing treatment modalities, processes and careful monitoring of new medications and technologies.10 Professional societies also have an important function in defining and promoting a universal minimum standard of care that should be implemented with the support of government policy makers.

Professional scientific societies can play a leading role in working to achieve recognition of intensive care medicine as a primary medical specialty as discussed above at the European level and beyond. Leadership will also be required in the definition and standardisation of intensive care training, ensuring both efficiency and quality.71

Leadership by scientific societies begins with an active collaboration between intensive care specialists and other medical specialties within each institution. Intensivists are ideally situated to coordinate activities from different specialties and encourage an atmosphere of open cooperation, especially in crisis situations.36,72

Medical institutions have an important role to play in the establishment of collaborations to ensure a high level of patient care, reduced costs and improved patient outcomes (www.ihi.org).66 These cooperative efforts may include quality assurance monitoring, scientific exchange or the sharing of expertise using electronic networks. One tool that may be required to achieve this goal is a common language which defines an ICU, an ICU patient, and a patient who should be admitted to the ICU; these definitions can then be universally applied to both outcome and quality assessment research. The application of scientific principles of peer review to quality assurance assessments may be beneficial and could be coordinated by institutional, governmental or scientific bodies.