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
—Timothy Buchman, PhD, MD, director, Emory University Center for Critical Care, Atlanta
Given the recent push for more outpatient treatment of less-critically-ill patients, many observers say the increased acuity of hospitalized patients—with more comorbidities—only exacerbates the mismatch between supply and demand. Making matters worse, providers are not evenly distributed throughout the country, with many smaller and rural hospitals already facing an acute shortage of intensivist services.
As a result, many hospitalists have been forced to step into the breach. According to SHM’s 2012 State of Hospital Medicine survey, 83.5% of responding nonacademic adult medicine groups said they routinely provide care for patients in an ICU setting, along with 27.9% of academic HM groups.
“So we have hospitalists who, either by choice or by default, care for patients who they may or may not be fully qualified to manage,” Dr. Siegal says. Practically speaking, he and his coauthors assert, the question of whether hospitalists should be in the ICU is now moot. The real question is how to ensure that those providers can deliver safe and effective care.
Experience vs. Training
Currently, internists who have completed fellowships in such specialties as pulmonary medicine, nephrology, and infectious disease can complete a one-year critical-care fellowship to obtain board certification. Experienced hospitalists have questioned the requirement that they instead complete a two-year fellowship, with no consideration given to the relevant clinical experience and maturity gained after years of hospitalist practice. In addition, they argue, it is logistically and financially unrealistic to expect a large cadre of experienced hospitalists to abandon their practices for two years to pursue critical-care training.
But Dr. Baumann says subpar internal-medicine residency requirements deserve much of the blame for offering inadequate training. “Critical care is a blend of critical thinking skills and procedural skills. Both of those are diminished tremendously in the current programs for internal medicine,” he says. “It’s really an indictment of our current training of internal-medicine residents now.”
SCCM, for its part, is sticking to its guns, albeit more quietly. When asked for comment, a spokesman issued a carefully worded statement that reads, “The paper reflects the society’s concerns regarding workforce shortages and the realities of today’s environment.”
The SHM/SCCM proposal makes sense provided that hospitalists are realistic about the types of patients they’ll see, says Timothy Buchman, PhD, MD, director of Emory University’s Center for Critical Care in Atlanta. “No one in their right mind will say one year is as good as two years. That would be folly,” he says. “On the other hand, that’s not the question. The question is, ‘Can we structure training that is competency-focused, so that the majority of people who enter the training will achieve the necessary levels of competency within a year?’”
Derek Angus, MD, chair of critical-care medicine at the University of Pittsburgh Medical Center and lead author of the 2000 study chronicling the intensivist shortfall, is more ambivalent. “Hospitalists and intensivists have to work hand in hand. In many ways, they are the two groups that run inpatient hospital medicine,” he says. In that respect, sorting out and streamlining training pathways might be a good idea.
“On the other hand, all of intensive-care training in the United States is a little thin in comparison to what goes on in many other countries,” Dr. Angus adds. “If anything, I would like to be seeing more vigorous training. So creating one more pathway that helps reinforce pretty light training feels like accreditation, in general, may be moving slightly in the wrong direction.”
Dr. Buchman and other observers view the debate as a difference in opinion among well-meaning people who are passionate about patient care. And they concede that no one knows yet who may be right.
“We do know that advanced training is required. We do know that it should be competency-focused,” Dr. Buchman says. “But what we don’t know is how long it’s really going to take to get to the competency levels that we believe are necessary to care for the patients.”
That point may provide one important opening for further discussions. Dr. Baumann agrees that the real issues are how to define critical-care competencies, how to measure them, and how to ensure that trainees prove their mettle as competent providers. “It really shouldn’t be time-based; it should be outcome-based,” he says.
The SHM/SCCM proposal, Dr. Siegal says, should be viewed as a conversation-starter. The true test will be whether everyone can reach an agreement on how to evaluate whether an ICU caregiver has attained the necessary knowledge, skills, and attitudes—and how relevant professional experience should factor into discussions over the length of training required for intensivist certification.
A Tiered Solution
The concept of tiered ICU care—already used in neonatal ICUs—might offer another opening for productive debate. “Can patients who are not that critically ill be managed by someone who hasn’t done that much critical-care training?” Dr. Angus asks. He believes it’s possible, provided patients are properly sorted and that hospitalists aren’t put in the uncomfortable position of managing medical conditions that they see only rarely. He has no problem, though, envisioning a tiered system in which fully trained intensivists spend most of their time managing the sickest patients, while other providers—including hospitalists—care for patients at intermediate risk.
Hospitalists have greeted the idea cautiously, noting that a two-tiered model might be difficult to define and standardize, and that it could present logistical challenges around transferring patients. However, Daniel D. Dressler, MD, MSc, SFHM, FACP, associate professor of internal medicine at Emory University School of Medicine and coauthor of the SHM/SCCM position paper, led a recent study that offers at least some support for a risk-based system.6
Overall, the study found no statistically significant difference in the length of stay or inpatient mortality rates for ICU patients cared for by hospitalist-led or intensivist-led teams. Among mechanically ventilated patients with intermediate illness severity, though, the study suggested that intensivist-led care resulted in a lower length of stay in both the hospital and ICU, as well as in a trend toward reduced inpatient mortality. “There may be some value in designing or developing a stratification system,” Dr. Dressler says, “but it definitely needs more study.”
In the meantime, Dr. Dressler says, more rapid solutions are needed. And although he says he understands and respects many of the doubts expressed about the SHM/SCCM proposal, he also believes some of the fear might be based on anecdotes about individual hospitalists who were deemed unlikely to thrive in an ICU environment. “For each person like that, we also know 10 or 20 people who might do really well” with just a year of additional training, says Dr. Dressler, a former SHM board member.
Now that both sides clearly have the attention of the other, leaders say they hope the opening salvos give way to more temperate discussions about how to move more skilled providers to the front lines.
“Health professionals are a smart and clever lot,” says Mary Stahl, RN, MSN, ACNS-BC, CCNS-CMC, CCRN, immediate past president of AACN and a clinical nurse specialist at the Mid America Heart Institute at Saint Luke’s Hospital in Kansas City, Mo. “I’m confident we’ll develop an effective solution—maybe several—by focusing on the fundamental belief that patients’ needs must drive caregivers’ knowledge and skills.”
Bryn Nelson is a freelance medical writer in Seattle.
- Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med. 2012;7:359-364.
- Baumann MH, Simpson SQ, Stahl M, et al. First, do no harm: less training ≠ quality care. Chest. 2012;142:5-7.
- Milstein A, Galvin RS, Delbanco SF, et al. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract. 2000;3:313-316.
- Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.
- Angus DC, Shorr AF, White A, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016-1024.
- Wise KR, Akopov VA, Williams BR Jr., Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189.