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Teaching intensive care unit administration during critical care medicine training programs
Journal of Critical Care (2008) 23, 251–252
Editorial
Teaching intensive care unit administration during critical care medicine training programs The responsibilities of intensivists continue to expand with the emergence of a growing population in need of critical care support [1]. Patients requiring intensive care unit (ICU) monitoring have complex medical problems that frequently require evaluations from consultants and a variety of allied health professionals [2]. Critical care specialists have the challenging task of integrating these recommendations into evidenced-based, cost-effective patient-care plans [3]. These “non-clinical” decisions not only influence patient care but also have a profound impact on hospital budgets [3,4]. For instance, critical care is responsible for approximately 1% of the nations' gross national product, 10% of the nation's hospital beds, and 30% of the nation's acute hospital costs [4]. These data suggest that the day-to-day practice of clinical critical care medicine (CCM) should include managerial and administrative competence—attributes not traditionally taught in medical school, residency training programs, or fellowships [5-7]. Critical care medicine is the one of only a few subspecialties required by the Accreditation Council of Graduate Medical Education (ACGME) to provide a nonclinical curriculum in the area of administration, management, economics, and resource utilization [5]. Similar guidelines apply to all CCM programs, independent of primary specialty (eg, surgery, anesthesiology, internal medicine, or pediatrics) [5]. The importance of developing this skill set among young intensivists is underscored by the emergence of divisions and departments of critical care composed of not only physicians but also respiratory therapists and clinical pharmacists. Large multidisciplinary divisions require physician leadership with administrative competence [4]. Critical care fellows will ultimately be faced with the challenge to succeed as leaders of clinical, educational, and academic research programs in a subspecialty where they may be responsible for a substantial portion of institutional budgets [4]. In 1989, Section 405 of the New York State Health Code was created to restrict resident work hours in New 0883-9441/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
York, and on July 1, 2003, the ACGME mandated that these guidelines be enforced nationally [8,9]. As a result of this policy, resident work hours are now limited to 80 hours per week, averaged during a 4-week period, including inhouse call responsibilities. In this era of strict limitations to resident work hours, program directors of CCM training programs have the burden of creating a curriculum that both prepares trainees to master the extremes of medical/ surgical illness and provide a formal curriculum in business administration [5]. Although administrative competency is a prerequisite for many ICU directors, it is not known whether graduates of CCM fellowship programs are adequately prepared in this area [6,7]. A recent survey of 259 pediatric intensivists suggested that graduates were not sufficiently prepared for careers that rely on managerial and administrative skills. Overall, respondents felt only “somewhat prepared” for the 20 leadership and management items surveyed and were least prepared to manage conflict within a team, manage conflict with other groups, and manage stress effectively [6]. The assertion that most trainees are inadequately prepared to handle managerial issues in clinical critical care was also supported by results of a nationwide survey of 216 accredited CCM programs. In this survey, only 12% of the 139 respondents provided didactic training in areas of budget development and management. Similarly, regional/national administrative issues and managed care were part of a formal curriculum in only 32% of the critical care programs whose program directors responded to the survey. Overall, greater than 50% of CCM training programs provided formal instruction in 5 administrative topics: ethics, severity scoring systems, medical/legal issues, performance improvement, and clinical pathways. The ACGME has recently initiated a new paradigm in the accreditation process of graduate medical education programs. The ACGME's outcomes project is an educational initiative that focuses on a programs “actual accomplishments” (ie, educational outcomes) rather than a program's
252
Editorial
potential to educate through compliance with existing requirements (http://www.acgme.org/outcome/project/OutIntro.htm). As a result of this new policy, residency and fellowship programs now require their house staff to obtain competencies in 6 areas: patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice. Systemsbased practices continue to gain great importance in critical care fellowship training programs because they focus on administrative/business concepts, including cost containment, finance, and team leadership. In essence, systemsbased practices test the house officers' ability to implement various aspects of health care delivery systems and understand the financial implications of their use [6,7,10-16]. The importance of training intensivists to manage hospital resources in the most cost-effective manor is obvious; however, exactly how to provide this specialized training is less clear [4,5]. Most junior attendings are expected to develop administrative skills either by trial and error or through mentoring by senior ICU attendings [14]. The demands placed on many junior attendings practicing clinical CCM present a major obstacle to on-the-job training. In a university hospital setting, junior faculty members are faced with challenging educational and research obligations, whereas in the private sector, junior attendings have rigorous work schedules, including 24-hour in-house clinical responsibilities. It is likely that CCM leadership positions of the future will require highly skilled individuals with administrative expertise and insight into methods of cost containment. In view of this ever-expanding role of the intensivist, a formal curriculum seems to be a better option than on-the-job training. The ACGME requirements for formal administration/ managerial skills training of CCM fellows underscore the growing role of intensivists as administrators whose decisions impact on hospital budgets [4]. Program directors have at their disposal a number of options for incorporating a meaningful business training plan into a traditional CCM curriculum. The exposure to real-life business/managerial issues will provide a valuable experience for CCM fellows and allow for a smooth transition into a role of junior attending and multidisciplinary team leader. James Gasperino MD, PhD Richard Brilli MD, FCCM Vladimir Kvetan MD Division of Critical Care Medicine Department of Medicine Albert Einstein College of Medicine Bronx, NY 10467, USA E-mail address: [email protected] doi:10.1016/j.jcrc.2008.01.010
References [1] Marik PE. Management of the critically ill geriatric patient. Crit Care Med 2006;34:S176-82. [2] Nfor TK, Walsh TS, Prescott RJ. The impact of organ failures and their relationship with outcome in intensive care: analysis of a prospective multicentre database of adult admissions. Anaesthesia 2006;61:731-8. [3] Brilli R, Spevetz A, Branson R, Campell Cohen H, Dasta JF, Harvy MA, et al. American College of Critical Care Medicine Task Force on Models of Critical Care Delivery. The American College of Critical Care Medicine Guidelines for Definition of an Intensivist and the Practice of Critical Care Medicine. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19. [4] Kvetan V. Management training in critical care medicine. Ann Acad Med Singapore 1998;27:444-7. [5] Guidelines for advanced training for physicians in critical care. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1997;25:1601-7. [6] Stockwell DC, Pollack MM, Turenne WM, Slonim AD. Leadership and management training of pediatric intensivists: how do we gain our skills? Pediatr Crit Care Med 2005;6:665-70. [7] Brilli R, Kvetan V, Albrecht R, Biagas K, Cheng E, Ferguson T, et al. The Graduate Medical Education Committee of the Society of Critical Care Medicine. Teaching intensive care unit administration during critical care medicine training: a national survey. Crit Care Med 2001;29 [Abs 241]. [8] NY Comp Codes R & Reg. Title 10 § 405.4 (1989). Albany, NY: New York State Department of Health. [9] Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004;141:851-7. [10] Lusco VC, Martinez SA, Polk HC. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005;189:11-31. [11] Larson DB, Chandler M, Forman HP. MD/MBA Programs in the United States: evidence of a change in health care leadership. Academic Medicine 2003;78:335-41. [12] Powner DJ, Thomas EA. Research curricula in critical care fellowships —a survey. Crit Care Med 1996;24:1079-82. [13] Young MA, Hough DE, Peskin MR. Outcomes of a program in business education for physicians and other health care professionals. Southern Med J 2003;96:1000-6. [14] Ghidotti N. Business basics. Physicians often learn practice management by trial and error. Journal of the Arkansas Medical Society 2004;101:136-8. [15] Meltzer BA. Everything I needed to know about medical management I learned in acting school. Physician Exec 2002;28:48-50. [16] Iverson RL. Establishing an administrative core curriculum for critical care medicine physicians. Crit Care Clin 1993;9:437-42.
Editorial
Teaching intensive care unit administration during critical care medicine training programs The responsibilities of intensivists continue to expand with the emergence of a growing population in need of critical care support [1]. Patients requiring intensive care unit (ICU) monitoring have complex medical problems that frequently require evaluations from consultants and a variety of allied health professionals [2]. Critical care specialists have the challenging task of integrating these recommendations into evidenced-based, cost-effective patient-care plans [3]. These “non-clinical” decisions not only influence patient care but also have a profound impact on hospital budgets [3,4]. For instance, critical care is responsible for approximately 1% of the nations' gross national product, 10% of the nation's hospital beds, and 30% of the nation's acute hospital costs [4]. These data suggest that the day-to-day practice of clinical critical care medicine (CCM) should include managerial and administrative competence—attributes not traditionally taught in medical school, residency training programs, or fellowships [5-7]. Critical care medicine is the one of only a few subspecialties required by the Accreditation Council of Graduate Medical Education (ACGME) to provide a nonclinical curriculum in the area of administration, management, economics, and resource utilization [5]. Similar guidelines apply to all CCM programs, independent of primary specialty (eg, surgery, anesthesiology, internal medicine, or pediatrics) [5]. The importance of developing this skill set among young intensivists is underscored by the emergence of divisions and departments of critical care composed of not only physicians but also respiratory therapists and clinical pharmacists. Large multidisciplinary divisions require physician leadership with administrative competence [4]. Critical care fellows will ultimately be faced with the challenge to succeed as leaders of clinical, educational, and academic research programs in a subspecialty where they may be responsible for a substantial portion of institutional budgets [4]. In 1989, Section 405 of the New York State Health Code was created to restrict resident work hours in New 0883-9441/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
York, and on July 1, 2003, the ACGME mandated that these guidelines be enforced nationally [8,9]. As a result of this policy, resident work hours are now limited to 80 hours per week, averaged during a 4-week period, including inhouse call responsibilities. In this era of strict limitations to resident work hours, program directors of CCM training programs have the burden of creating a curriculum that both prepares trainees to master the extremes of medical/ surgical illness and provide a formal curriculum in business administration [5]. Although administrative competency is a prerequisite for many ICU directors, it is not known whether graduates of CCM fellowship programs are adequately prepared in this area [6,7]. A recent survey of 259 pediatric intensivists suggested that graduates were not sufficiently prepared for careers that rely on managerial and administrative skills. Overall, respondents felt only “somewhat prepared” for the 20 leadership and management items surveyed and were least prepared to manage conflict within a team, manage conflict with other groups, and manage stress effectively [6]. The assertion that most trainees are inadequately prepared to handle managerial issues in clinical critical care was also supported by results of a nationwide survey of 216 accredited CCM programs. In this survey, only 12% of the 139 respondents provided didactic training in areas of budget development and management. Similarly, regional/national administrative issues and managed care were part of a formal curriculum in only 32% of the critical care programs whose program directors responded to the survey. Overall, greater than 50% of CCM training programs provided formal instruction in 5 administrative topics: ethics, severity scoring systems, medical/legal issues, performance improvement, and clinical pathways. The ACGME has recently initiated a new paradigm in the accreditation process of graduate medical education programs. The ACGME's outcomes project is an educational initiative that focuses on a programs “actual accomplishments” (ie, educational outcomes) rather than a program's
252
Editorial
potential to educate through compliance with existing requirements (http://www.acgme.org/outcome/project/OutIntro.htm). As a result of this new policy, residency and fellowship programs now require their house staff to obtain competencies in 6 areas: patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice. Systemsbased practices continue to gain great importance in critical care fellowship training programs because they focus on administrative/business concepts, including cost containment, finance, and team leadership. In essence, systemsbased practices test the house officers' ability to implement various aspects of health care delivery systems and understand the financial implications of their use [6,7,10-16]. The importance of training intensivists to manage hospital resources in the most cost-effective manor is obvious; however, exactly how to provide this specialized training is less clear [4,5]. Most junior attendings are expected to develop administrative skills either by trial and error or through mentoring by senior ICU attendings [14]. The demands placed on many junior attendings practicing clinical CCM present a major obstacle to on-the-job training. In a university hospital setting, junior faculty members are faced with challenging educational and research obligations, whereas in the private sector, junior attendings have rigorous work schedules, including 24-hour in-house clinical responsibilities. It is likely that CCM leadership positions of the future will require highly skilled individuals with administrative expertise and insight into methods of cost containment. In view of this ever-expanding role of the intensivist, a formal curriculum seems to be a better option than on-the-job training. The ACGME requirements for formal administration/ managerial skills training of CCM fellows underscore the growing role of intensivists as administrators whose decisions impact on hospital budgets [4]. Program directors have at their disposal a number of options for incorporating a meaningful business training plan into a traditional CCM curriculum. The exposure to real-life business/managerial issues will provide a valuable experience for CCM fellows and allow for a smooth transition into a role of junior attending and multidisciplinary team leader. James Gasperino MD, PhD Richard Brilli MD, FCCM Vladimir Kvetan MD Division of Critical Care Medicine Department of Medicine Albert Einstein College of Medicine Bronx, NY 10467, USA E-mail address: [email protected] doi:10.1016/j.jcrc.2008.01.010
References [1] Marik PE. Management of the critically ill geriatric patient. Crit Care Med 2006;34:S176-82. [2] Nfor TK, Walsh TS, Prescott RJ. The impact of organ failures and their relationship with outcome in intensive care: analysis of a prospective multicentre database of adult admissions. Anaesthesia 2006;61:731-8. [3] Brilli R, Spevetz A, Branson R, Campell Cohen H, Dasta JF, Harvy MA, et al. American College of Critical Care Medicine Task Force on Models of Critical Care Delivery. The American College of Critical Care Medicine Guidelines for Definition of an Intensivist and the Practice of Critical Care Medicine. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19. [4] Kvetan V. Management training in critical care medicine. Ann Acad Med Singapore 1998;27:444-7. [5] Guidelines for advanced training for physicians in critical care. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1997;25:1601-7. [6] Stockwell DC, Pollack MM, Turenne WM, Slonim AD. Leadership and management training of pediatric intensivists: how do we gain our skills? Pediatr Crit Care Med 2005;6:665-70. [7] Brilli R, Kvetan V, Albrecht R, Biagas K, Cheng E, Ferguson T, et al. The Graduate Medical Education Committee of the Society of Critical Care Medicine. Teaching intensive care unit administration during critical care medicine training: a national survey. Crit Care Med 2001;29 [Abs 241]. [8] NY Comp Codes R & Reg. Title 10 § 405.4 (1989). Albany, NY: New York State Department of Health. [9] Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med 2004;141:851-7. [10] Lusco VC, Martinez SA, Polk HC. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005;189:11-31. [11] Larson DB, Chandler M, Forman HP. MD/MBA Programs in the United States: evidence of a change in health care leadership. Academic Medicine 2003;78:335-41. [12] Powner DJ, Thomas EA. Research curricula in critical care fellowships —a survey. Crit Care Med 1996;24:1079-82. [13] Young MA, Hough DE, Peskin MR. Outcomes of a program in business education for physicians and other health care professionals. Southern Med J 2003;96:1000-6. [14] Ghidotti N. Business basics. Physicians often learn practice management by trial and error. Journal of the Arkansas Medical Society 2004;101:136-8. [15] Meltzer BA. Everything I needed to know about medical management I learned in acting school. Physician Exec 2002;28:48-50. [16] Iverson RL. Establishing an administrative core curriculum for critical care medicine physicians. Crit Care Clin 1993;9:437-42.