“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.