Multisociety Task Force Recommendations

Transcription

1 Multisociety Task Force Recommenations Multisociety Task Force Recommenations of Competencies in Pulmonary an Critical Care Meicine John D. Buckley 1, Doreen J. Arizzo-Harris 2, Alison S. Clay 3, J. Ranall Curtis 4, Robert M. Kotloff 5, Scott M. Lorin 6, Susan Murin 7, Curtis N. Sessler 8, Paul L. Rogers 9, Mark J. Rosen 10, Antoinette Spevetz 11, Talmage E. King, Jr. 12, Atul Malhotra 13, an Polly E. Parsons 14 1 Henry For Hospital, Iniana University School of Meicine, Inianapolis, Iniana; 2 New York University School of Meicine, New York; 3 Departments of Meicine an Surgery, Duke University, Durham, North Carolina; 4 Division of Pulmonary an Critical Care, University of Washington, Seattle, Washington; 5 University of Pennsylvania, Philaelphia, Pennsylvania; 6 Mount Sinai School of Meicine, New York; 7 University of California at Davis, Davis, California; 8 Virginia Commonwealth University Health System Meical College of Virginia Physicians an Hospitals, Richmon, Virginia; 9 University of Pittsburgh, Pittsburgh, Pennsylvania; 10 North Shore University Hospital an Long Islan Jewish Health System, Long Islan, New York; 11 Cooper University Hospital, Camen, New Jersey; 12 University of California at San Francisco, San Francisco, California; 13 Brigham an Women s Hospital an Harvar Meical School, Boston, Massachusetts; an 14 University of Vermont School of Meicine, Burlington, Vermont Rationale: Numerous accreiting organizations are calling for competency-base meical eucation that woul help efine specific specialties an serve as a founation for ongoing assessment throughout a practitioner s career. Pulmonary Meicine an Critical Care Meicine are two istinct subspecialties, yet many iniviual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties ientifies eucational goals for trainees an guies practitioners through their lifelong learning. Objectives: To efine specific competencies for grauates of fellowships in Pulmonary Meicine an Internal Meicine-base Critical Care. Methos: A Task Force compose of representatives from key stakeholer societies convene to ientify an efine specific competencies for both isciplines. Beginning with a etaile list of existing competencies from iverse sources, the Task Force categorize each item into one of six core competency heaings. Each iniviual item was reviewe by committee members iniviually, in group meetings, an conference calls. Nominal group methos were use for most items to retain the views an opinions of the minority perspective. Controversial items unerwent aitional whole group iscussions with iterative moifie-delphi techniques. Consensus was ultimately etermine by a simple majority vote. Measurements an Main Results: The Task Force ientifie an efine 327 specific competencies for Internal Meicine-base Critical Care an 276 for Pulmonary Meicine, each with a esignation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. Conclusions: Specific competencies in Pulmonary an Critical Care Meicine can be ientifie an efine using a multisociety collaborative approach. These recommenations serve as a starting point an set the stage for future moification to facilitate maximum quality of care as the specialties evolve. Keywors: clinical competence fellowships an scholarships eucation; professional curriculum Supporte by the American Thoracic Society. Aitional support was provie by the American College of Chest Physicians an the Society of Critical Care Meicine. Corresponence an requests for reprints shoul be aresse to John D. Buckley, M.D., M.P.H., Iniana University School of Meicine, Emerson Hall 317, 545 Barnhill Drive, Inianapolis, IN johnbuck@iupui.eu This article has an online supplement, which is accessible from this issue s table of contents at Am J Respir Crit Care Me Vol 180. pp , 2009 DOI: /rccm ST Internet aress: BACKGROUND For nearly 15 years, eucational organizations incluing the Council on Grauate Meical Eucation, Pew Health Professions Commission, Association of American Meical Colleges, Feerate Council of Internal Meicine, Association of Program Directors of Surgery, an Royal College of Physicians an Surgeons of Canaa have all calle for improvement in the knowlege an skills of specialist physicians (1). With support from the Robert Woo Johnson Founation, the Accreitation Council for Grauate Meical Eucation (ACGME) began its evelopment of their six core competencies for resients an fellows (2). Concurrently, the American Boar of Meical Specialties ha begun eveloping competencies for practicing physicians. Soon thereafter, these two leaing organizations agree upon six core competencies, setting the stage for an organize continuum of competencies from the training level to lifelong physician evelopment (1). In his inaugural column in the May 2008 ACGME Bulletin, their new Chief Executive Officer share the next steps in eveloping agreement on the specific competencies for each iscipline, which they refer to as Milestones. Following the ientification of these competencies, efforts woul be irecte at implementing common assessment tools to ocument achievement of the Milestones (3). Base on the Dreyfus moel of knowlege evelopment, the ACGME recognizes the competent stage of evelopment takes place uring resiency an fellowship training, an the proficient stage occurs early in inepenent practice (1). As part of their efforts to efine the Milestones for iniviual isciplines, the ACGME is soliciting input from specialty societies an eucational communities to efine specific Milestones. However, there are concerns that efine sets of econtextualize specific skills, although tangible an practical, may also fail to measure, or may even interfere with, achieving the greater goal of personal an professional evelopment an socialization into a profession (4). The ACGME acknowlege these concerns, but oes not support a minimalist approach to competency assessment, arguing that the professional evelopment of competent or proficient physicians relies on specific an formative feeback on an iniviual s performance in meaningful competencies. The ACGME s Milestones are intene to be important markers of abilities an are esigne to ensure trainees, professional communities, an the public that basic measures of eucational processes are achieve (5).

2 Multisociety Task Force Recommenations 291 TASK FORCE DEVELOPMENT AND CHARGE In the fall of 2006, John Heffner, then Presient of American Thoracic Society, calle for a task force to efine specific competencies for Pulmonary an Critical Care Meicine. Representatives from the American Boar of Internal Meicine (ABIM), American College of Chest Physicians (ACCP), Association of Pulmonary an Critical Care Meicine Program Directors (APCCMPD), American Thoracic Society (ATS), an the Society of Critical Care Meicine (SCCM) convene an were charge with ientifying an efining the competencies for Pulmonary Meicine an for Internal Meicine-base Critical Care that trainees shoul attain uring their formal training an that shoul be retaine through lifelong learning uring practice. The goal i not encompass eveloping an entire curriculum inclusive of teaching techniques an assessment methos but focuse on ientifying eucational outcomes base on the ACGME general competencies both for trainees an inepenent practitioners. The Task Force approache its charge in two phases. First, it focuse on efining specific competencies for Critical Care Meicine. Critical Care Meicine is recognize as istinctly ifferent from Surgical Critical Care an Anesthesia Critical Care by the ACGME an ABIM, although consierable overlap is acknowlege. Secon, the Task Force evelope specific competencies for Pulmonary Meicine. The Task Force mae every effort to align these competencies with the ACGME Milestones that shoul be achieve by the en of formal fellowship training for internists in Critical Care Meicine or Pulmonary Meicine, with the unerstaning that iniviuals traine in combine Pulmonary Critical Care Meicine programs woul meet the competencies for both. METHODS Ientification of Task Force Members The Chairperson of the Task Force (P.E.P.) worke with leaership from the ABIM, ACCP, APCCMPD, ATS, an SCCM to ientify an inclue a group of participants with iverse interests in clinical meicine, eucation, an research, but who were all involve in training fellows in one or both of these isciplines. Literature Review an Ientification of Core Competencies In December of 2006, a member of the Task Force (J.D.B.) collate into one ocument the lists of existing competencies from the websites of the ACGME (Pulmonary/Critical Care Meicine Program Requirements) (6), Harmonize Eucation in Respiratory Meicine for European Specialists (HERMES) (7), Competency-Base Training in Intensive Care Meicine in Europe (CoBaTrICE) (8), the ABIM (Subspecialty in Pulmonary/Critical Care Meicine) (9), an the Alliance for Acaemic Internal Meicine (AAIM) Eucation Reesign Task Force raft ocuments for the Core of Internal Meicine (10). Many of the competencies ientifie by these groups were similar if not ientical. Task Force members were encourage to list aitional competencies uring several brainstorming sessions. In a systematic manner using a moifie Delphi approach (11), each specific competency was categorize into one of the six core competency heaings outline by the ACGME. These core competencies are: 1. Communication an Interpersonal Skills 2. Meical Knowlege 3. Patient Care 4. Practice-base Learning an Improvement 5. Professionalism 6. Systems-base Practice When specific competencies coul fit uner multiple core competency heaings, they were assigne to the single most appropriate core competency to minimize reunancy. Competencies manate by the ABIM an ACGME (release in 2006) were marke with an asterisk to guie the Task Force by acknowleging current training requirements in the Unite States. The compilation was entere into a atabase an submitte to the Task Force for review. Task Force Review Process The Task Force worke via conference calls, exchanges, an in person on multiple occasions uring 2007 an While eveloping this ocument, the Task Force consiere the unintene consequences of these recommenations incluing their use by creentialing an certifying organizations that coul impact current training program requirements, maintenance of certification, meical licensing, an hospital creentialing. There was early emphasis on acknowleging that the competencies in Pulmonary Meicine an Critical Care Meicine overlappe, but that there were istinct ifferences. With approximately 90% of Critical Care physicians in the Unite States having backgrouns in Internal Meicine (12), the Task Force focuse on Internal Meicine-base Critical Care Meicine. Future efforts will ientify explicit commonalities an ifferences that may exist between Critical Care Meicine physicians an those Critical Care physicians who enter practice from training pathways in Surgery an Anesthesiology. The initial compilation from the process outline above was use as a starting point for eveloping a final, multisociety summary of specific competencies for both Critical Care Meicine an Pulmonary Meicine. Moifications, aitions, an eletions were conucte using several techniques: 1. Iniviual member review of each item in the initial compilation; 2. Brainstorming at in-person meetings an by conference call; 3. Nominal group methos for most items to retain the view an opinions of the minority perspective; 4. Whole group iscussions an voting on controversial ichotomous issues with ecisions etermine by a simple majority vote; 5. Iterative, moifie Delphi techniques incluing istribution of the competencies a minimum of three times to achieve consensus on the final list of competencies. Each item in the ocument was score iniviually using the following classification system base on the CoBaTrICE moel (8): 0: No aitional knowlege an experience beyon that obtaine in Internal Meicine training OR not relevant to the iscipline being consiere (Critical Care Meicine or Pulmonary Meicine). 1: Knowlege/behavior/proceural skill relevant to the practice of the iscipline but primary expertise/proficiency is within the purview of another specialty such that consultation or further inepth literature review is typically require; 2: Knowlege/behavior/proceural skill funamental to the practice of the iscipline. Expertise/proficiency in this area is expecte. Finally, the competencies an scoring were istribute to the executive leaership of the ACCP, APCCMPD, ATS, an SCCM for review an feeback. This step serve to obtain official approval from each organization an was a final step in valiation of the results of the Task Force results. TABLE 1. NUMBERS OF RECOMMENDED SPECIFIC COMPETENCIES Core Competency Heaing Number of Specific Competencies Critical Care Meicine Pulmonary Meicine Communication an Interpersonal Skills Meical Knowlege Patient Care Practice-base Learning an Improvement Professionalism Systems-base Practice Total

3 292 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL TABLE 2. EXAMPLES OF SPECIFIC COMPETENCIES IN MEDICAL KNOWLEDGE FOR CRITICAL CARE MEDICINE (PANEL A) AND PULMONARY MEDICINE (PANEL B) PANEL A: CRITICAL CARE MEDICINE Evaluation an management of common respiratory signs an symptoms incluing yspnea, cough, chest pain, wheezing, an 1.0 hemoptysis Respiratory iseases focusing on evelopmental preispositions an general pathophysiology 1.0 Respiratory iseases incluing management principles Pulmonary manifestations of systemic iseases incluing collagen vascular isease an iseases that are primary in other organs 1.0 Obstructive lung iseases: Asthma 1.0 Bronchitis 1.0 Emphysema 1.0 Bronchiolitis 1.0 Bronchiectasis 1.0 Respiratory failure ue to obstructive lung isease Diseases of the upper airway Structural efect of the airway incluing stenosis, malacia, tracheal tear, an fistula Upper airway obstruction Vocal cor ysfunction 1.0 Gastro-esophageal reflux isease 1.0 Pulmonary malignancy (primary an metastatic) Lung cancer 1.0 Meiastinal an chest wall tumors Paraneoplastic synromes Pulmonary infections Respiratory failure ue to infections Upper respiratory tract infections 1.0 Viral lower respiratory tract infections Community-acquire an health-care associate pneumonias Parapneumonic effusions an empyema Lung abscess 1.0 Epiemic lung infections (e.g., influenza, SARS, avian influenza, anthrax) Tuberculosis incluing latent, active, pulmonary, extra-pulmonary 1.0 Nontuberculous mycobacterial isease 1.0 Fungal 1.0 In the immunocompromise host 1.0 PANEL B: PULMONARY MEDICINE Evaluation an management of common respiratory signs an symptoms incluing yspnea, cough, chest pain, wheezing, an hemoptysis Respiratory iseases focusing on evelopmental preispositions an general pathophysiology Developmental biology 1.0 Biochemistry an physiology, incluing cell an molecular biology, an immunology, as they relate to pulmonary iseases Genetics an molecular biology as they relate to pulmonary iseases Pulmonary manifestations of systemic iseases, incluing collagen vascular isease an iseases that are primary in other organs Genetic an evelopmental isorers of the respiratory system, incluing cystic fibrosis Histopathologic patterns of respiratory inflammation an malignancy Respiratory iseases incluing management principles Pulmonary manifestations of systemic iseases incluing collagen vascular isease an iseases that are primary in other organs Obstructive lung iseases: Asthma Bronchitis Emphysema Bronchiolitis Bronchiectasis Respiratory failure ue to obstructive lung isease Diseases of the upper airway Structural efect of the airway incluing stenosis, malacia, tracheal tear, an fistula Upper airway isease Vocal cor ysfunction Gastroesophageal reflux isease Pulmonary malignancy (primary an metastatic) Lung cancer Metastatic cancer to the respiratory system Mesothelioma Benign respiratory tumors Meiastinal an chest wall tumors Paraneoplastic synromes (Continue )

4 Multisociety Task Force Recommenations 293 TABLE 2. (CONTINUED) PANEL B: PULMONARY MEDICINE (CONTINUED) Pulmonary infections Respiratory failure ue to infections Upper an lower respiratory tract infections Viral lower respiratory tract infections Community-acquire an healthcare associate pneumonias Parapneumonic effusions an empyema Lung abscess Epiemic lung infections (e.g., influenza, SARS, avian influenza, anthrax) Tuberculosis incluing latent, active, pulmonary, extrapulmonary Nontuberculous mycobacterial isease Fungal In the immunocompromise host RESULTS The Task Force ientifie, efine, an categorize 327 specific competencies for Internal Meicine-base Critical Care an 276 specific competencies for Pulmonary Meicine (see Table 1). Examples of selecte Critical Care Meicine an Pulmonary Meicine specific competencies in meical knowlege an technical proceures (from Patient Care) are shown in Tables 2 an 3, respectively. This Task Force s full consensus recommenations of all specific competencies for Pulmonary Meicine an Critical Care Meicine are liste in Table E1 an Table E2 of the online supplement, respectively, an are also available in upate form on a joint society website at ( Only those competencies that were aware a final score of one or two are inclue. Definitions an scoring of the various competencies were not unanimous an reflecte the iversity of current practice. However, all members of the task force approve the final competencies. To obtain a score of one or two, training programs shoul have specific curricula to istinguish this competency from general Internal Meicine. Specific knowlege, skills, an behaviors are inclue as competencies for Critical Care Meicine, Pulmonary Meicine, or both. The committee limite the competencies to those that reflect current practice rather than future goals. The results represent a consensus effort an shoul be viewe as live ocuments that are a starting point. The Task Force expects that these recommenations will evolve with increase input, changing practice patterns, an new scientific an treatment evelopments. The societies have agree to ongoing support of a multisociety task force to maintain the competency ocuments an ensure that they can be reviewe an change in a timely manner as neee. Training Programs Dictate the Require Clinical Experiences During the scoring of the iniviual competencies it became clear that there is a ifference in the philosophy of iniviual training programs with regar to the require clinical experiences. This is most evient in the nonmeical aspects of critical care that are generally outsie the purview of Intensivists from Internal Meicine backgrouns, such as the evaluation an management of abominal compartment synrome, intracranial hemorrhage, an increase intracranial pressure. Although some members of the committee consiere these to be core knowlege (assigne a score of two), others i not (score of one). The origin of these philosophical ifferences may resie, in part, in the preominant patient population care for by the Critical Care Meicine physician. Training programs base primarily in meical ICUs may perceive competencies ifferently than those base in multiisciplinary ICUs (i.e., combine Meical-Surgical ICUs). Furthermore, several competencies reflect various isciplinespecific perspectives of specific iseases. For example, a Pulmonary perspective of asthma may require competency in unerstaning the mechanisms an pathophysiology of asthma, but a Critical Care Meicine perspective may require a competency in unerstaning the physiology an management of respiratory failure cause by asthma. Another example woul be the iagnosis an management of severe exacerbations of systemic lupus erythematosis (SLE). Whereas the perspectives an competencies for Rheumatology an Critical Care Meicine specialists will iffer for SLE, these ifferences may be appropriate. Where possible, the competencies were evelope sie-by-sie with the perspective of other isciplines. For example, in eepwater iving injuries, a pulmonary specialist woul be expecte to screen subjects appropriately an to conuct a risk assessment, but a Critical Care Meicine specialist woul be expecte to manage the acute illness. Of course, many iniviual physicians may have training, experience, an competency in both. Discussion an Future Direction Leaership in Critical Care Meicine an in Pulmonary Meicine encompasses a broa array of clinical experts, creentialing an certifying organizations, an specialty societies. This multisociety Task Force is an initial, collaborative attempt to ientify current, specific competencies in Critical Care Meicine an Pulmonary Meicine in tanem. Since this ocument was first evelope, we have recognize that several items may nee to be ae, moifie, or elete, unerscoring the nee for continuous review an revision that reflects the ongoing acquisition of meical knowlege, changing clinical practice, an working knowlege of how to eliver the best possible care to patients. Defining specific competencies is necessary to ensure effective training of clinicians. As meical schools an resiencies outline their own specific competencies, we must coorinate our efforts in eveloping an efficient continuum of eucation that transcens formal training. This ocument represents a consensus recommenation of current, funamental Critical Care Meicine an Pulmonary Meicine competencies. It is a starting point that will guie future eucational goals an professional evelopment. Consensus on the competencies sets the stage for other activities essential to eucational evelopment, incluing: Creation of curricula for specific competencies; Valiating assessment methos; Ientifying unique milestones for each competency that must be met before moving from one phase of eucation

5 294 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL TABLE 3. EXAMPLES OF SPECIFIC COMPETENCIES IN PROCEDURAL SKILLS (FROM PATIENT CARE) FOR CRITICAL CARE MEDICINE (PANEL A) AND PULMONARY MEDICINE (PANEL B) PANEL A: CRITICAL CARE MEDICINE Interpretation of sputum, bronchopulmonary secretions, an pleural flui 1.0 Arterial puncture for bloo gas etermination an arterial catheter placement Principles, inications an limitations of pulse oximetry Physical principles, inications an limitations of en tial CO 2 monitoring Pulmonary function testing to assess respiratory mechanics an gas exchange, incluing spirometry, flow volume stuies, lung volumes, iffusing capacity Arterial bloo gas analysis Airway management incluing enotracheal intubation Management of the ifficult airway Moes an principles of mechanical ventilation invasive an noninvasive Moes an principles of oxygen supplementation Tracheostomy tube management an ecannulation Percutaneous tracheostomy 1.0 Emergent carioversion an efibrillation Knowlege of the inications, contrainications, complications, an basic principles of intra-aortic counter pulsation balloon pump Knowlege of the inications, contrainications, complications, an basic principles of right an left ventricular assist evices 1.0 Temporary transvenous pacemaker insertion 1.0 Lumbar puncture Brain eath etermination in accorance with local laws an stanars Knowlege of the inications, contrainications, complications, an basic principles of intracranial pressure monitors Manage an establishe epiural infusion 1.0 Diagnostic an therapeutic thoracentesis Chest tube insertion an maintanence of the tube an rainage systems Insertion of ecompression neele for tension pneumothorax Diagnostic an therapeutic paracentesis Central venous catheter placement (subclavian, femoral, jugular) with/without ultrasoun guiance Set-up an operation of hemoynamic an respiratory monitoring systems Interpretation of hemoynamic an oxygen elivery an extraction ata Principles of extracorporeal membrane oxygenation (ECMO) 1.0 Insertion an flotation of pulmonary artery catheter Diagnostic bronchoscopy incluing airway examination an bronchoalveolar lavage 1.0 Therapeutic bronchoscopy through an artificial airway for secretion removal Knowlege of woun vacuum management systems 1.0 Principles, inications, an limitations of intraabominal pressure monitoring Unerstans principles, techniquesan complication of insertion of gastrooesophageal balloon tamponae tube (e.g., Sengstaken-Blakemore) Principles an application of therapeutic hypothermia Principles an moes of nutritional support Imaging techniques commonly employe in the evaluation of patients with critical illness an/or pulmonary isorers 1.0 Basic interpretation of chest raiograph Other imaging techniques 1.0 PANEL B: PULMONARY MEDICINE Interpretation of sputum, bronchopulmonary secretions, an pleural flui results Interpretation of lung tissue for infectious agents, cytology, an histopathology Arterial puncture for bloo gas etermination an arterial catheter placement Principles, inications an limitations of pulse oximetry Physical principles, inications an limitations of en tial CO 2 monitoring Pulmonary function testing to assess respiratory mechanics an gas exchange, incluing spirometry, flow volume stuies, lung volumes, iffusing capacity, arterial bloo gas analysis, inhalation challenges, an exercise stuies Arterial bloo gas analysis Inhalation challenges incluing methacholine Exercise stuies Airway management incluing enotracheal intubation Management of the ifficult airway Moes an principles of mechanical ventilation - invasive an non-invasive Moes an principles of oxygen supplementation Tracheostomy tube management an ecannulation Percutaneous tracheostomy 1.0 Emergent carioversion an efibirllation 1.0 Knowlege of the inications, contrainications, complications, an basic principles of intraaortic counter pulsation balloon pump Knowlege of the inications, contrainications, complications, an basic principles of right an left ventricular assist evices 1.0 Brain eath etermination in accorance with local laws an stanars 1.0 Diagnostic an therapeutic thoracentesis Chest tube insertion an maintanence of the tube an rainage systems Insertion of ecompression neele for tension pneumothorax Diagnostic an therapeutic paracentesis 1.0 Central venous catheter placement (subclavian, femoral, jugular) with/without U.S. guiance Set-up an operation of various monitoring systems Interpretation of hemoynamic an oxygen elivery an extraction ata (Continue )

6 Multisociety Task Force Recommenations 295 TABLE 3. (CONTINUED) PANEL B: PULMONARY MEDICINE (CONTINUED) Principles of extracorporeal membrane oxygenation (ECMO) 1.0 Insertion an flotation of pulmonary artery catheter 1.0 Flexible bronchoscopy incluing airway examination, bronchoalveolar lavage, secretion removal, transbronchial fine neele aspiration, transbronchial biopsy, enobronchial biopsy (minimum of 50) Diagnostic bronchoscopy incluing transbronchial fine neele aspiration, transbronchial biopsy, enobronchial biopsy Therapeutic bronchoscopy through an artificial airway for secretion removal Unerstan principles an techniques for seation, analgesia, an elirium management Critical review of polysomnographic reports Polysomnographic recognition of various patterns of apnea an hypopnea The utility an interpretation of cariopulmonary monitoring in sleep-relate isorers Imaging techniques commonly employe in the evaluation of patients with critical illness an/or pulmonary isorers 1.0 Basic interpretation of chest raiograph Other imaging techniques 1.0 to another (i.e., meical stuent, to resient, to fellow, to inepenent practitioner); Nurturing an iniviual s self-reflection in a continuous manner that fosters the cycle of experience, reflection, conceptualization, an further practice (13). Many challenges remain, incluing faculty evelopment, ientifying an supporting eicate teachers an program irectors, an the nee for aitional vali methos of competency assessment. In an era of increasing financial uncertainty of the support for meical eucation, the consoliation of efforts an resources has the best chance for success. We alreay have strong agreement between the ACGME an ABMS on efinitions of the core competencies (1). Engagement of all key stakeholers across the spectrum of training levels an meical societies is essential to facilitating a cohesive, effective mechanism for avancing the meical profession. This Task Force s members an supporting societies hope that projects like this will continue to support collaborative interactions as the fiels of Critical Care Meicine an Pulmonary Meicine evolve. Each iscipline will evolve inepenently an also in conjunction with the other. Continue collaboration coul result in a centralize review process for etermining the relevance an priority of specific competencies, coorinating the evelopment of teaching methos, researching assessment techniques, an ientifying milestones. In contrast to a network of silos, a multisociety effort is more likely to help our profession move forwar an integrate with creentialing an certifying organizations, resiency an fellowship training programs, an meical schools. Conflict of Interest Statement: J.D.B. serve as a Meical Malpractice Expert Witness for Kitch Law Firm an receive $1,001 to $5,000. D.A.-H. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. A.S.C. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. J.R.C. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. R.M.K. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.M.L. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.M. owns stocks or options in Genentech $10,001 to $50,000. C.N.S. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. P.L.R. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. M.J.R. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. A.S. oes not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. T.E.K. receive consultancy fees from AstraZeneca, Centocor, Genzyme, Human Genome Sciences, $1,001 to $5,000; an GlaxoSmithKline, $10,000 to $50,000. He serves on the Boar or Avisory Boar for Actelion, InterMune, $10,001 to $50,000; Nektar, $5,001 to $10,000; ImmuneWorks, $1,001 to $5,000; an CV Therapeutics, up to $1,000. He has receive lecture fees from Pfizer an has been a consultant to Gilea for up to $1,000; an Millennium, Serono, an Boehringer Ingelheim, $1,001 to $5,000. A.M. has been a consultant for Respironics, NMT Meical, Apnex Meical, Inspiration Meical, Restore Meical, Itamar Meical, Pfizer, Metronics, an Cephalon, $10,001 to $50,000. He has receive lecture fees from Pfizer, $1,001 to $5,000; an he has receive grant support from Restore Meical, Respironics, an Sepracor for $100,001 an more. P.E.P. receives royalties from Elsevier Publishers, $1,001 to $5,000; an is Eitor for Up-to-Date, Critical Care section, $10,001 to $50,000. Acknowlegment: The Task Force thanks Shane McDermott, Barbara Horner, Miriam Roriguez, an Elizabeth Guzman from the American Thoracic Society who provie aministrative support. References 1. 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