The long-simmering debate over whether and how hospitalists might help solve the worsening shortage of critical-care physicians is beginning to boil over.
In June, SHM and the Society of Critical Care Medicine (SCCM) issued a joint position paper proposing an expedited, one-year, critical-care fellowship for hospitalists with at least three years of clinical job experience, in lieu of the two-year fellowship now required for board certification.1
“Bringing qualified hospitalists into the critical-care workforce through rigorous sanctioned and accredited one-year training programs,” the paper asserted, “will open a new intensivist training pipeline and potentially offer more critically ill patients the benefits of providers who are unequivocally qualified to care for them.”
The backlash was swift and sharp. In a strongly worded editorial response published in July, the American College of Chest Physicians (ACCP) and the American Association of Critical-Care Nurses (AACN) declared that one year of fellowship training is inadequate for HM physicians to achieve competence in critical-care medicine.2 “No, the perfect should not be the enemy of the good in our efforts to craft solutions,” the editorial stated. “But the current imperfect SCCM/SHM proposal is an enemy of the existing good training processes already in place.”
HM leaders counter that the current strategies for bolstering the ranks of board-certified intensivists simply aren’t working, and that creative, outside-the-box thinking is required to solve the dilemma.
“Hospitalists are rapidly becoming a dominant, if not the dominant, block of physicians who are providing critical care in the United States. You can decide, if you want, whether that’s good or bad, but that’s the reality,” says Eric Siegal, MD, SFHM, lead author of the SHM/SCCM position paper, director of critical-care medicine at Aurora St. Luke’s Medical Center in Milwaukee, and an SHM board member. Given the escalating shortage of intensivists, he says, he believes that concerned stakeholders can either try to help develop the skills and knowledge of those hospitalists already in the ICU or “hope that a whole bunch of hospitalists suddenly decide to abandon their practices and complete two-year medical
Intensivist leaders say that less training will do nothing to improve patient outcomes. “The reality is that hospitalists are doing it. The question should be, ‘Are they doing it well or at the detriment of the patient?’” asks Michael Baumann, MD, MS, FCCP, professor of medicine in the division of pulmonary, critical-care, and sleep medicine at the University of Mississippi Medical Center in Jackson. “The patient is the one who loses if we have somebody pinch-hitting, which is really what we’re talking about here,” adds Dr. Baumann, lead author of the ACCP/AACN editorial.
Despite the heated rhetoric, interviews with leaders on both sides suggest an eagerness to move forward in trying to collectively solve a problem that has vexed the entire medical community.
In 2000, the Leapfrog Group, a Washington, D.C.-based consortium of major healthcare purchasers focused on improving the safety, quality, and value of care, recommended that all ICUs should be staffed with physicians certified in critical-care medicine.3 As part of its rationale, the group cited research suggesting that greater intensivist use can yield better patient outcomes.
But a seminal study published the same year hinted at just how difficult meeting Leapfrog’s ambitious goal might be. Based on the trajectory of supply and demand, the authors forecast a 22% shortfall in intensivist hours by 2020, and a 35% shortfall by 2030, mainly due to a surge in demand from an aging U.S. population.4 A follow-up report in 2006 estimated that 53% of the nation’s ICU units had no intensivist coverage at all, and that only 4% of adult ICUs were meeting the full Leapfrog standards of high-intensity ICU staffing, dedicated attending physician coverage during the day, and dedicated coverage by any physician at night.5