- Email: [email protected]
The shortage of critical care physicians: Is there a solution?
Journal of Critical Care 29 (2014) 1121–1122
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Correspondence
The shortage of critical care physicians: Is there a solution?☆,☆☆,★,★★ Manuel Lois, MD, FCCP ⁎ John Peter Smith Hospital, Department of Medicine, 1500 South Main, Fort Worth, TX 76104
a r t i c l e
i n f o
Keywords: Fellowship Training Critical care Work force Outcomes Patient care
a b s t r a c t Objective: The objective of this study is to provide a solution to the critical care physician shortage. Data sources: The data sources are Medline search of published articles regarding the critical care physician shortage, the current training model, and the roll of family physicians. Data extraction: The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses. At the same time, it has been suggested that a highly staffed intensive care unit (ICU) including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing. Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field. Published estimates indicate that intensivists currently provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions. Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship. Conclusions: Family Practice is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. This group that can potentially be trained in critical care and help solve the crisis has been prevented from doing so. © 2014 Elsevier Inc. All rights reserved.
The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses [1]. The “Baby boomer” generation (born between 1946 and 1964) just started retiring in 2011. Based on the article by Martin et al [2], the incidence of sepsis, one of the most common medical intensive care unit (ICU) diagnoses, dramatically increases after age 65 years. We may have drastically underestimated critical care needs for the future [3]. At the same time, it has been suggested that a highly staffed ICU including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing [2,4]. Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years [1] or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field [1,4]. Published estimates indicate that intensivists currently
☆ Same as correspondence address and address for reprints. ☆☆ No reprints will be ordered at this time.
★ No financial support received. ★★ The name of the institution, the highest degrees, and institutional affiliation are as above.
⁎ Tel.: +817 702-8929. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jcrc.2014.08.001 0883-9441/© 2014 Elsevier Inc. All rights reserved.
provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions [1,5]. Public policies affect the future supply of intensivists [6]. On the one hand, the demand has risen from private purchasers, but at the same time, Medicare threatens to cut reimbursement. In addition, there is no new support for graduate medical education. These issues threaten the training and income of intensivists, removing the appeal to younger physicians who would be dissuaded by the lower income and the lifestyle burden compared with other specialties. Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship. This will likely help delay the crisis but in no means helps solve the problem. Family Practice (FP) is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. In spite of this, the FP scope of practice is constantly being challenged by specialists all over the
1122
Correspondence / Journal of Critical Care 29 (2014) 1121–1122
country…but these same specialists are not practicing, where the biggest needs are. Although physicians in most FP residency programs hospitalize their patients at community hospitals, FP residency faculty have medical ICU privileges at 38% of these university hospitals, and intensive care patients at these hospitals are generally cared for by specialists and house staff in internal medicine or critical care [7]. In spite of this critical shortage of critical care–certified physicians, family practitioners are not allowed to pursue training in critical care that would lead to certification at the completion of a fellowship. In addition, a requirement to establish a fellowship in critical care (at least through the Medicine pathway) is the presence of an internal medicine program [8-11]. The rational for these requirements is unclear and obviously is limiting a significant proportion of a potential work force in critical care. Family Practice residents have training similar if not better than some internal medicine programs. If anything, their training is even broader, bringing in some pediatrics as well as general surgery. In many FP programs, there is added emphasis on outpatient medicine, but all Internal Medicine programs have outpatient rotations. There is no requirement for Internal Medicine to do a “hospitalist” tract to qualify for critical care fellowship. If it is felt that a “minimum” number of months in an ICU rotation is needed before fellowship in critical care that can be stated and should be consistent across both medicine and FP. By the time a fellowship decision is made, there would be ample time to alter the third year. Regardless, if a fellowship in critical care is open to the FP physicians, they would be subjected to the same rigorous training and education as anyone trained in critical care. Reluctantly, The American Council Graduate Medical Education and American Board of Internal Medicine have acknowledged that medical critical care training is achievable in less than 2 years, by allowing those who enter or complete accredited 2-year fellowships in other medical specialties to obtain critical care certification with a single additional year of critical care training [12]. One proposed solution to the ongoing critical care workforce shortage in the United States by The Society of Critical Care Medicine and the Society of Hospital Medicine is the creation of a 1-year expedited critical care training program leading to certification for hospitalists who have completed 3 years in practice [13]. It is as if the second year of critical care training is not value added. The American College of Chest Physicians (ACCP), the American Association of Critical Care Nurses, and a consensus from the current ACCP president's group (the Critical Care Network Steering Committee and the ACCP Strategic Work Action Team) have all published their concerns that this fast track 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine [14].
Then, why if a medical specialty fellow can become competent in critical care with an additional year of critical care training? Is it unreasonable to believe that FP physicians cannot become competent by undergoing the 2-year critical care pathway as required from internal medicine? In addition, how is it that the proposed fast track program for hospitalists will provide adequate training to achieve competence in critical care? And why it is felt that a family physician cannot receive adequate training in a rigorous 2- or 3-year dedicated critical care program? I propose that the solution is in our hands by revisiting the requirements and facilitating other specialties access to critical care training. The Accreditation Council of Graduate Medical Education, the Society of Critical Care Physicians, and other governing societies and colleges need to reconsider these other pathways for the training in critical care that will help shorten the bridge between supply and demand. References [1] Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J. 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: 2762–70. [2] Martin GS, Mannino DM, Moss IM. The effect of age on the development and outcome of adult sepsis. Crit Care Med 2006;34:15–21. [3] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151–62. [4] Milstein A, Galvin RS, Delbanco SF, Salber P, Buck CR. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract 2000;3:313–6. [5] Task Force on Guidelines, Society of Critical Care Medicine Guidelines for categorization of services for the critically ill patient. Crit Care Med 1991;19:279–85. [6] Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002;21:140–54. [7] Weiss BD. Family physicians in university hospital intensive care units. J Fam Pract 1983;17(4):693–6. [8] ACGME Internal Medicine program requirements. Available at: http://www. acgme.org/acwebsite/rrc_140/140_prindex.asp. [9] ACGME program requirements for resident education in internal medicine. Available at: http://www.acgme.org/acWebsite/reviewComment/140_internal_ medicine_PRs_R&C.pdf. [10] ACGME program requirements for graduate medical education in surgical critical care. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/ 442_critical_care_surgery_01012009.pdf. [11] ACGME program requirements for graduate medical education in anesthesiology critical care medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/045pr101.pdf. [12] American Board of Internal Medicine: critical care medicine policies. Available at: http://www.abim.org/certification/policies/imss/ccm.aspx. [13] 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. Crit Care Med 2012;40(6):1952–6. [14] Gutterman DA, Baumann MH, Simpson SQ, Stahl M, Raoof S, Marciniuk DD. First, do no harm: less training ≠ quality care. Am J Crit Care 2012;21:227–30.
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Correspondence
The shortage of critical care physicians: Is there a solution?☆,☆☆,★,★★ Manuel Lois, MD, FCCP ⁎ John Peter Smith Hospital, Department of Medicine, 1500 South Main, Fort Worth, TX 76104
a r t i c l e
i n f o
Keywords: Fellowship Training Critical care Work force Outcomes Patient care
a b s t r a c t Objective: The objective of this study is to provide a solution to the critical care physician shortage. Data sources: The data sources are Medline search of published articles regarding the critical care physician shortage, the current training model, and the roll of family physicians. Data extraction: The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses. At the same time, it has been suggested that a highly staffed intensive care unit (ICU) including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing. Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field. Published estimates indicate that intensivists currently provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions. Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship. Conclusions: Family Practice is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. This group that can potentially be trained in critical care and help solve the crisis has been prevented from doing so. © 2014 Elsevier Inc. All rights reserved.
The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses [1]. The “Baby boomer” generation (born between 1946 and 1964) just started retiring in 2011. Based on the article by Martin et al [2], the incidence of sepsis, one of the most common medical intensive care unit (ICU) diagnoses, dramatically increases after age 65 years. We may have drastically underestimated critical care needs for the future [3]. At the same time, it has been suggested that a highly staffed ICU including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing [2,4]. Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years [1] or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field [1,4]. Published estimates indicate that intensivists currently
☆ Same as correspondence address and address for reprints. ☆☆ No reprints will be ordered at this time.
★ No financial support received. ★★ The name of the institution, the highest degrees, and institutional affiliation are as above.
⁎ Tel.: +817 702-8929. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jcrc.2014.08.001 0883-9441/© 2014 Elsevier Inc. All rights reserved.
provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions [1,5]. Public policies affect the future supply of intensivists [6]. On the one hand, the demand has risen from private purchasers, but at the same time, Medicare threatens to cut reimbursement. In addition, there is no new support for graduate medical education. These issues threaten the training and income of intensivists, removing the appeal to younger physicians who would be dissuaded by the lower income and the lifestyle burden compared with other specialties. Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship. This will likely help delay the crisis but in no means helps solve the problem. Family Practice (FP) is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. In spite of this, the FP scope of practice is constantly being challenged by specialists all over the
1122
Correspondence / Journal of Critical Care 29 (2014) 1121–1122
country…but these same specialists are not practicing, where the biggest needs are. Although physicians in most FP residency programs hospitalize their patients at community hospitals, FP residency faculty have medical ICU privileges at 38% of these university hospitals, and intensive care patients at these hospitals are generally cared for by specialists and house staff in internal medicine or critical care [7]. In spite of this critical shortage of critical care–certified physicians, family practitioners are not allowed to pursue training in critical care that would lead to certification at the completion of a fellowship. In addition, a requirement to establish a fellowship in critical care (at least through the Medicine pathway) is the presence of an internal medicine program [8-11]. The rational for these requirements is unclear and obviously is limiting a significant proportion of a potential work force in critical care. Family Practice residents have training similar if not better than some internal medicine programs. If anything, their training is even broader, bringing in some pediatrics as well as general surgery. In many FP programs, there is added emphasis on outpatient medicine, but all Internal Medicine programs have outpatient rotations. There is no requirement for Internal Medicine to do a “hospitalist” tract to qualify for critical care fellowship. If it is felt that a “minimum” number of months in an ICU rotation is needed before fellowship in critical care that can be stated and should be consistent across both medicine and FP. By the time a fellowship decision is made, there would be ample time to alter the third year. Regardless, if a fellowship in critical care is open to the FP physicians, they would be subjected to the same rigorous training and education as anyone trained in critical care. Reluctantly, The American Council Graduate Medical Education and American Board of Internal Medicine have acknowledged that medical critical care training is achievable in less than 2 years, by allowing those who enter or complete accredited 2-year fellowships in other medical specialties to obtain critical care certification with a single additional year of critical care training [12]. One proposed solution to the ongoing critical care workforce shortage in the United States by The Society of Critical Care Medicine and the Society of Hospital Medicine is the creation of a 1-year expedited critical care training program leading to certification for hospitalists who have completed 3 years in practice [13]. It is as if the second year of critical care training is not value added. The American College of Chest Physicians (ACCP), the American Association of Critical Care Nurses, and a consensus from the current ACCP president's group (the Critical Care Network Steering Committee and the ACCP Strategic Work Action Team) have all published their concerns that this fast track 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine [14].
Then, why if a medical specialty fellow can become competent in critical care with an additional year of critical care training? Is it unreasonable to believe that FP physicians cannot become competent by undergoing the 2-year critical care pathway as required from internal medicine? In addition, how is it that the proposed fast track program for hospitalists will provide adequate training to achieve competence in critical care? And why it is felt that a family physician cannot receive adequate training in a rigorous 2- or 3-year dedicated critical care program? I propose that the solution is in our hands by revisiting the requirements and facilitating other specialties access to critical care training. The Accreditation Council of Graduate Medical Education, the Society of Critical Care Physicians, and other governing societies and colleges need to reconsider these other pathways for the training in critical care that will help shorten the bridge between supply and demand. References [1] Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J. 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: 2762–70. [2] Martin GS, Mannino DM, Moss IM. The effect of age on the development and outcome of adult sepsis. Crit Care Med 2006;34:15–21. [3] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151–62. [4] Milstein A, Galvin RS, Delbanco SF, Salber P, Buck CR. Improving the safety of health care: the Leapfrog initiative. Eff Clin Pract 2000;3:313–6. [5] Task Force on Guidelines, Society of Critical Care Medicine Guidelines for categorization of services for the critically ill patient. Crit Care Med 1991;19:279–85. [6] Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002;21:140–54. [7] Weiss BD. Family physicians in university hospital intensive care units. J Fam Pract 1983;17(4):693–6. [8] ACGME Internal Medicine program requirements. Available at: http://www. acgme.org/acwebsite/rrc_140/140_prindex.asp. [9] ACGME program requirements for resident education in internal medicine. Available at: http://www.acgme.org/acWebsite/reviewComment/140_internal_ medicine_PRs_R&C.pdf. [10] ACGME program requirements for graduate medical education in surgical critical care. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/ 442_critical_care_surgery_01012009.pdf. [11] ACGME program requirements for graduate medical education in anesthesiology critical care medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/045pr101.pdf. [12] American Board of Internal Medicine: critical care medicine policies. Available at: http://www.abim.org/certification/policies/imss/ccm.aspx. [13] 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. Crit Care Med 2012;40(6):1952–6. [14] Gutterman DA, Baumann MH, Simpson SQ, Stahl M, Raoof S, Marciniuk DD. First, do no harm: less training ≠ quality care. Am J Crit Care 2012;21:227–30.