Patient Care

Care Critical


There is a brewing crisis in critical-care medicine, a crisis that already is impacting HM. It would be easier for hospitalists to look the other way and say, “This is not our problem.” Make no mistake: It is our problem. There are not enough intensive-care physicians to go around.

In my generation, most physicians who trained in pulmonary and critical-care medicine thought they would do some office care, some bronchoscopies, and some critical care for the first several years of their professional lives. Few imagined that, in their 60s, their practice would still include rescuing patients from death at 2 a.m. Couple the intensity of care with such a demanding lifestyle, and it is hardly surprising that many critical-care doctors seek less-stressful practices (e.g., sleep medicine) or retirement.

New physicians who see the work-life imbalance are shying away from critical care in significant enough numbers, yet the demand for these doctors is growing. Whether that shift is due to the attraction of careers in HM, emergency medicine, or other IM specialties, or the perceived negatives to being a full-time intensivist, is beside the point. The medical workforce needs more critical-care physicians. And we are not going to be able to meet this need by assuming we will be able to recruit and train more surgeons, anesthesiologists, or pulmonary physicians in traditional critical-care pathways.

It is no surprise hospitalists are called upon to fill the critical-care gap. SHM surveys show that 92% of hospitalists include ICU care in their practice. While hospitalists clearly do not have the training or skills to replace the intensivist, we clearly are witnessing a “scope creep.”

The situation is further complicated by workforce shortages on the rest of the ICU healthcare team. Many senior ICU nurses are reaching the end of their careers, and the pipeline to replace them is anything but robust. And all this comes at a time when the acuity of hospitalized patients is increasing and the demands for ICU expertise is at its height.

It is no surprise that hospitalists are called upon to fill the critical-care gap. SHM surveys show that 92% of hospitalists include ICU care in their practice. While hospitalists clearly do not have the training or skills to replace the intensivist, we clearly are witnessing a “scope creep.” Hospitalists are being asked to stretch their skills to fill the void in critical care.

Competence Question

The response to this is manifest in many ways. For example, steadily increasing numbers of hospitalists attend SHM’s annual critical-care precourses, and our procedures courses invariably sell out. These brief courses are important to hospitalists and their patients. Yet a day (or even two) of focused training for hospitalists will not raise their skill set to replace or even augment critical-care-trained physicians at their hospitals. The patients will keep coming and continue to need the expertise for their most-acute-care needs. Something must be done.

There are pockets of experiments on filling the increasing critical-care gap. Emory University’s Center for Critical Care in Atlanta will soon launch an experimental, HM-critical-care training program that will attempt to develop and verify critical-care competencies in just one postgraduate year after IM residency. A complementary approach could include a hospitalist-focused track within the three years of IM residency to include less outpatient medicine and more intensive-care training. This could be part of a broader restructuring of internal and family medicine residencies, which recognize the career paths (and needs) of their residents as some enter hospital-focused practice (e.g., as hospitalists, cardiologists, intensivists) and some concentrate more on the patient outside the hospital (e.g., primary care, endocrinology, rheumatology).

As training evolves, there will be practical issues of credentialing. Currently, a general-IM-trained hospitalist is required to complete a two-year fellowship in critical care to be a specialist. Interestingly, if one’s residency training is in surgery, anesthesia, or rheumatology, that physician requires only one additional year in critical care to become eligible for added/special qualifications in critical-care medicine. What, precisely, is the carryover of the longer residency experience that makes it possible to attain competency in critical care in half the training time?

There also is the risk that we will create a workforce that includes the intensivist-lite—someone who does not have complete, recognized training in critical care but has more than the typical hospitalist, and is perceived as “better than having no intensivist.” Is this in the best interest of our patients or our discipline?

Supply Solutions

There are other approaches to the workforce challenge beyond asking hospitalists to step away from practice for an additional year or two of training. As in other aspects of the hospital workforce, it is time to examine alternative deployment of the entire healthcare team. If intensivists and hospitalists are in limited supply, we need to revisit their roles and further look for opportunities to engage acute-care nurse practitioners, physician assistants, RNs, and others on the healthcare team to meet the expanding needs of our patients and our hospitals.

Another strategy would include regionalization of healthcare in population centers with multiple hospitals. In Orange County, Calif., where I live, there are 33 hospitals for 3 million people, each with some form of an ICU. Is it time to set standards of coverage and expertise so that 10 to 15 hospitals can provide a fully staffed ICU, and the other hospitals refer their most-acute patients rather than be stretched to staff their ICUs at a time of workforce shortages? Is it time to do what we did with trauma centers and set various levels of care so that not every hospital can or should be doing the most intense and costly level of care?

SHM, HM, and, most importantly, hospitalists find themselves in the midst of this growing problem. We must be part of the solution.

It is important to recognize the significant variability in the intensivist skill sets that individual hospitalists and HM groups currently possess; the variance creates hurdles in being able to step up and fill the critical-care gap. I’ve heard about hospitalists pausing their practices to obtain additional training in critical care. Hospitals across America are (or soon will be) scrambling to integrate their hospitalists and intensivists to maximize coverage and expertise. SHM has noticed an increased demand on hospitalists to increase knowledge and skills so they can extend the local coverage of critically ill patients.

It is time for SHM to clearly understand how this sea change is affecting you professionally and personally, because you practice on the frontlines of our nation’s hospitals.

It is time for SHM to engage our colleagues in the ICU—critical-care physicians and their professional societies—to understand their perspective and initiatives on this growing crisis.

It is time for SHM to engage medical educators in residency and fellowship training to explore potential changes in the curriculum—changes aimed at young physicians proceeding through their training that yield hospital-based physicians better prepared to enter the hospital environment of the 21st century.

And SHM may need to engage the boards and other credentialing bodies to look for flexibility that will reflect today’s realities, attract the best-trained physicians to care for the most-acutely-ill patients, and protect our patients by demanding expertise and training at the most appropriate levels. TH

Dr. Wellikson is CEO of SHM.

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