Intensive care medicine (ICM) is a relatively young discipline, and even more recent is the attempt to provide formal certifications for those with a particular qualification or specialists in this field: the first examination dedicated to intensivists was introduced by the Australian Faculty of Anesthetists in 1979 (1). In many countries, intensive care medicine developed as part of other specialties: both surgical and several medical specialties developed their own ICM training programs, splitting ICM knowledge in specific sub-sections. This approach was overcome starting from the 1970s, when in Europe and in the United States ICM training programs became a fundamental part of the debate on how ICM should develop. So far, three main models can be identified worldwide, namely the development of ICM: 1) within related medical or surgical specialties, 2) as a stand-alone recognized specialty or 3) as a hybrid of these two ("super specialty"), as frequently occurs (2). Therefore, the ICM educational path can either consist in a complete stand-alone specialization school, a training program with multidisciplinary access with a common curriculum or, as other option, training programs available only for specific specialists, typically anesthesiologists (3). Anesthesiology includes anaesthesia, perioperative care, intensive care medicine, emergency medicine and pain therapy, and it acknowledged as a leading medical specialty in addressing issues of patient safety (4). For this reason, anesthesiology is the base specialty most frequently linked to ICM; others that provide access in some European countries include emergency medicine, internal and pulmonary medicine, cardiology, nephrology, neurosurgery, trauma, neonatology and paediatrics (5). Defining the professional figure of the intensivist, whose mandate is to take care of the critical ill patient and of everything is associated with him or her, including rehabilitation period after ICU discharge and families, is a noble purpose, but overlaps with several political issues (6). As of today, ICM does not fully satisfy the criteria to be recognized as primary specialty according to the European Directive 2005/36/EC on the recognition of professional qualifications since it was not approved as independent discipline by at least one third of the Member States according to the European Union of Medical Specialists (UEMS) (7). In Italy and several North-European countries, ICM is considered a natural development of anaesthesiology competences and formal training programs have been introduced. Conversely, in countries like Spain and Switzerland, ICM is considered as primary specialty. The United Kingdom is a leading country in the competence-based training of intensivists, and has a complex system of evaluation and certification of skills. Of notice, in many countries where ICM is a primary specialty, the first years of training are however spent in anaesthesiology. ICM is intrinsically multidisciplinary (8)

No abstract

F irst of all, we would like to thank Professor Kesecioğlu (1) for his historical perspective: it is important to put this discussion in the right context: as we all might be influenced by our personal experiences and the work environment where we grew up. We share with our colleague the commitment to improve and homogenise the standards of care in our intensive care units (ICU), and the call to improve skills and education of healthcare professionals, whose final goal is taking care of the critically ill patient. We recognize that from the polio epidemic to nowadays, the competences required to face critical conditions have gradually changed and different skills, apparently belonging to other specialties, have become crucial in the practice of intensive care medicine (ICM). Nonetheless, it is quite common, among different specialties, that a medical professional need to acquire additional competences not strictly related to his or her original background but shared with other specialties, in order to guarantee adequate management of the patient.Our patients are characterized by a complex overlap of several conditions, affecting his or her health status and commonly involving infections or acute cardiovascular, neurological, respiratory and renal function impairment (2). In taking care of these patients, a unique professional figure with a multidisciplinary preparation has to dedicate his or her work time entirely to the management of the illness per se, as well as related factors such as patients' and relatives' psychological status. The intensivist has to exercise his own leadership in order to coordinate all health professional roles that work around the critically ill patient, namely being a reference and also an interface between the patient and other specialists, when the competences of a single professional are insufficient. All these purposes are mandatory and not necessarily in contrast with the definition of the intensivist's professional role, whose education in ICM can be built based on other specialties, such as anaesthesiology as it is often the case in Europe. ICUs organization is different in many European countries and political and administrative measures have to be realized in order to create an optimal workplace to take care of critical patients (3). We are convinced that differences in ICUs management have to be solved at the local level, and creating a primary specialty would not necessarily be a solution. However, the Multidisciplinary Joint Committee in Intensive Care Medicine (MJCICM) should make efforts to have ICM recognized as area of 'particular expertise' at the European level (4). This kind of solution would not require changing the ICM education path in most of European countries, while gaining an institutional recognition suitable to obtain ICUs administrative and political 327