Philosophies of an Intensivist: Lessons from Osler
By Stephen W. Crawford, MD
If Dr. William Osler were alive today, what kind of doctor would he be? Would he have specialized? Would he have become certified in internal medicine? Would he have obtained subspecialty boards? In infectious diseases? Cardiology? I suspect he would have become a critical care physician.
In 1992, the Society of Critical Care Medicine provided guidelines for the definition of an intensivist and the practice of critical care medicine.1 These guidelines include specific training, certification, devotion of time, procedural and technical skills, as well as service as a team leader and unit manager. The practice of critical care is "defined by the needs of the critical care patient." These guidelines provide quantifiable requirements for the intensivist. However, I believe they are not complete in defining the qualitative aspects of an intensivist. Perhaps the intensivist is defined less by the place and type of work than by a fundamental approach to care.
Medical textbooks review the core knowledge base of critical care. The specialty residencies in internal medicine, surgery, and pediatrics teach physicians about acute organ failures, endocrinological emergencies, resuscitation, central line insertions, and other issues relevant to critical care. So why aren’t all these broadly-trained physicians "intensivists"? What is the difference between those specialists and intensivists? I think the fundamental distinction is not the knowledge base or ability to perform procedures. The distinction is one of philosophy. This philosophy allows the intensivist to render care and decision making in a manner distinct in rapidity and perspective.
I find that I tend to repeat common phrases to the physicians-in-training who I supervise. These aphorisms seem to summarize my philosophy toward critical care. I also realize that many of these aphorisms were earlier attributed to Osler. I want to share some of these with you.
The Routine Intensivist
The intensivist in not necessarily the smartest and most sophisticated of modern physicians. Rather, in many ways the intensivist is the most simplistic. The intensivist is redundant and compulsive. Osler observed, "The chief function of the consultant is to make the rectal examination that you have omitted."2 The compulsive repetition by an intensivist of the review of organ systems, examination, and laboratory data converts the data to information that is useful in decision making.
Often an intensivist does not treat disease by a specific name. Often, appropriate treatments are ordered because the approach to the problems was correct, even if the name of the original disease was not identified. The intensivist divides a problem into its smallest units and deals individually with each. The intensivist sorts problems into the least common denominators, simplifies the equations, approaches broad problems, and dissects and addresses the individual components. This is the "simple(ton)" approach: "When the clinical problem appears complicated, divide it and treat each component separately."
An example of this approach is the patient with septic shock syndrome and multi-organ failure. Defining the final diagnosis in a single term, such as "toxic shock," is not the relevant issue to the intensivist and is not crucial to the management in many instances. The important issues become the components of the problem: support of the blood pressure, the intravascular volume, renal function, cerebral blood flow and consciousness, ventilation, oxygenation, treatment of likely infection, etc. If proper care is given to each element, the outcome may be favorable. This approach stresses that many activities of the intensivist are not intrinsically curative, but rather, are supportive in nature.
The Starship Intensivist
In David Gerrold’s sci-fi novel, Voyage of the Star Wolf, the starship cadets are taught at the academy that "The crisis isn’t the crisis itself. The real crisis is what you do before it and after it."3 The emergencies in the ICU are relatively simple to deal with since there are defined treatments for most of them that most physicians studied during training. These emergencies are not the crises. Dealing effectively with the problems at hand is distinct from preventing them. Similar to that of the primary care provider, prophylaxis is a major ingredient of the philosophy of the intensivist.
Dealing with a problem that is yet out of sight, and still over the horizon, is the goal of the intensivist. This is the "avoid surprises (it’s not your birthday)" approach: "No complication should occur in the intensive care unit that you did not predict." The intensivist is not purely reactive, but rather proactive. The training of the intensivist should instill a constant vigilance that questions, "what problem will occur next?" This level of vigilance is neither intuitive nor reflexive (except among the most paranoid of us).
This vigilance requires an understanding of the pathophysiology at work in the patient: the predispositions to disease and the incidence of complications that attend the immunological and physiological status and local environment. At best, the intensivist recognizes that these predictions of future ill are tenuous prophecies. Thus, many intensivists assume that the safest is the "assume ignorance" approach: "Assume that all your diagnoses are incorrect and that all your treatments are inappropriate." This philosophical strategy heightens the vigilance, increases the awareness of inconsistencies in the physical examination or laboratory data, and engenders a constant reassessment of the situation. Also, this philosophy is not new. Osler stated, "Absolute diagnoses are unsafe and are made at the expense of conscience."2
The Timid Intensivist
The appropriate approach for many situations in the intensive care unit is the "don’t just do something, stand there!" approach. No treatment is often preferable to empirical treatment, or as Osler said, "Remember how much you do not know. Do not pour strange medicines into your patients."2 Collecting additional information about a situation often leads to clarity in the diagnosis. The information may take the form of a biopsy or a chemistry result. Most importantly, this strategy permits additional time to pass for the diagnosis to become manifest, or for the condition to resolve.
This strategy of caution and therapeutic skepticism has its place in the setting of crises, as well as in less urgent conditions. In the ICU, the more urgent and critical the apparent emergency, the bigger should be the first step—backwards. The contribution of the intensivist to resolving a crisis is not necessarily the immediate application of technical skill. The value of the intensivist is the view and assessment of the circumstances. The proper role is in seeing the larger picture, prioritizing, directing the activities efficiently, and imposing a calm command to the crisis. Restraint in the face of impending doom is not inbred in most of us, but learned through years of practical experience, or more recently, taught in a critical care medicine training program.
The Empirical Intensivist
For a given condition in the ICU a few interventions may be clearly appropriate, and many more are clearly wrong. A philosophy is necessary to cover the distance between these therapeutic extremes. In situations that do not have a proven effective treatment, empirical approaches are warranted. It requires confidence to recognize these situations when intervention clearly is either right or wrong. When the therapy is not known to be either, the intensivist recognizes that the approach must be empirical, that is, not based on controlled scientific research but purely experimental, speculative, and made on the basis of personal experience and biases. This requires the "NO guts, no glory" approach: "There is no room in medicine for half-hearted empiricism."4 When being pragmatic and applying therapy in the absence of scientific data, it helps to be aggressive enough to affect a demonstrable response. Ideally, there should be objective, measurable end points by which to gauge the effect. If the treatment is based on experience alone, the intensivist should hope to learn something from the experience. Half-hearted attempts at experimental treatment are likely to benefit neither the patient nor the physician. The common example of this approach is the administration of "industrial" doses of glucocorticoids as a "last-ditch" attempt to treat a seemingly "hopeless" case.
The Guilty Intensivist
Constant vigilance for complications by the intensivist is complemented by strong guilt. The appropriately guilty intensivist often takes the "Guilt is good (or the I went to Catholic school’)" approach and assumes that any deterioration in the patient’s condition is the intensivist’s fault. Iatrogenicity runs rampant in the ICU. It is safest, and often correct, to assign deleterious changes in the patient’s condition to ill-effects of treatments or medications. For example, the guilty intensivist removes the "bucking" patient from ventilatory support temporarily if necessary to evaluate for physiological problems, such as inefficient ventilation, insufficient tidal volume, or inadequate inspiratory flow rate. Sedation or neuromuscular blockade of the patient is used only after attempting to improve the "match" between the patient and the ventilator.
The Intensivist and Philosophy
Many good physicians will recognize common aspects of their approaches to patient care. The strategies applied by the intensivist are not exclusive to the specialty and have been expanded upon more eloquently by Osler in his aphorisms.2 The philosophical approach is important to critical care in the degree. The intensivist constantly is faced with crises that require immediate decision making with minimal information. A disciplined approach that is based on the most fundamental aspects of medicine is crucial. The basis for the actions of the intensivist are not distinct in substance from those of any good physician, but the degree to which the intensivist must adhere to the strategies is distinct. The margin for error and the time for empiricism are limited in the ICU, and, thus, the preformed philosophical underpinnings of the intensivist become the foundation for the patients’ chances for survival. There must be firm ground on which to stand and decisively form diagnostic and therapeutic decisions. For the intensivist, this ground is marked with various approaches. These approaches are lined with extreme vigilance, constant skepticism, repeated examination, guilt, and doggedness. The degree to which such approaches must be adhered is not intuitively obvious to or immediately obtained by all physicians. The intensivist-in-training should be shown the course. The goal of the academic intensivist is to make the way clear. From these analyses, generalizable approaches, a philosophy, are formed, used, and passed to the intensivist in training.
One can be an excellent physician in the image of Osler without being an intensivist. However, one cannot be an intensivist without practicing medicine as diligently as prescribed by Osler. The mere acquisition of certain technical skills and practice within the confines of an ICU is not sufficient to warrant the label of an "intensivist." The intensivist is first and foremost a physician in the Oslerian tradition. The academic intensivist should convey the true essence of the practice of medicine in the ICU which is one of degree; medicine practiced intensively and with intensity. v
Special thanks to Drs. Leonard D. Hudson, David J. Pierson, and David Ralph for their insights and inspirations.
1. Guidelines committee. Society of Critical Care Medicine. Guidelines for the definition of an intensivist and the practice of critical care medicine. Crit Care Med. 1992;20:540-542.
2. Bean RB, Bean WB, eds. Sir William Osler: Aphorisms from His Bedside Teachings and Writings. New York, NY: Henry Schuman; 1950.
3. Gerrold D. Voyage of the Star Wolf. New York, NY: Bantam Books; 1990.
4. Hudson, LD. Personal communication.