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.
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).
