SAN FRANCISCO – Hospitalists are the most logical source of physicians to fill a shortage of intensive care providers. Or, maybe it’s emergency physicians. But it could be internists, depending on which of three speakers at the Critical Care Congress you find most persuasive.
Whether it’s any of those specialties or all three, there are barriers to be overcome with each strategy, the speakers said in a session on critical care practitioners.
Dr. Stephen M. Pastores
Hospitalists already are doing critical care, Dr. Andrew D. Auerbach said. "Even if not hired primarily for that, they’re doing it anyway," said Dr. Auerbach, a hospitalist and researcher at the University of California, San Francisco. A 2010 study found that 34 of 72 open intensive care units in Michigan had hospitalists as ICU attending physicians (J. Hosp. Med. 2010;5:4-9). These included smaller hospitals outside major population centers, not just small community hospitals, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
Hospitalists in those settings become "the first-line providers in critical care" when, for example, a patient with respiratory failure and sepsis needs to go to the ICU at 2 a.m. "The pulmonologist is trying to do their best, but is at home. The emergency physician is in the emergency department trying to take care of broken legs and car crashes. The anesthesiologist is doing airways and epidurals up on the obstetrics floor."
These hospitalists need to be supported in their intensivist roles by "giving them the training – whether it be for an added certification or board certification, I don’t care," Dr. Auerbach said. Intensivists also could benefit by forging clinical partnerships with hospitalists to tap hospitalists’ expertise in sepsis care, patient monitoring, antimicrobial stewardship, comanaging surgical patients, and transitioning patient care, he suggested.
"Hospitalists want to go into critical care medicine but have been at times in limbo because there is no pathway for them except to do the 2 years of fellowship training," Dr. Stephen M. Pastores agreed in a separate presentation. "We need to help our hospitalists get to the promised land of the ICU," either by creating a shortened training pathway or by offering new incentives.
Dr. Franklin Michota
Community hospitals that want more intensivists could pay for hospitalists to pursue fellowship training and guarantee them an intensivist job when training is finished, said Dr. Pastores, director of the critical care fellowship program at Memorial Sloan-Kettering Cancer Center, New York, and a board-certified internist, pulmonologist, and intensivist there.
Hospitals that are determined to have intensivists run the ICU might consider that approach, which could offset the hassle of leaving one’s job and taking a temporary pay cut in order to pursue a critical care fellowship, Dr. Franklin A. Michota agreed in a phone interview. Or, they simply could offer higher salaries to recruit intensivists. "It’s a supply-and-demand phenomenon," said Dr. Michota, director of academic affairs in the department of hospitalist medicine at the Cleveland Clinic.
On the other hand, intensive care is within the scope and training of hospitalists, and any hospitalists working in ICUs should be pursuing critical care CME already, he added. Doing a 2-year critical care fellowship "on top of that won’t change the skill set" but will increase the salary that a physician can command, he said.
Besides hospitalists, Dr. Pastores sees greater possibilities from expanding the pipeline of internists into critical care.
"I’d argue that the internal medicine–based trained intensivists really have no competing responsibilities" compared with pulmonologists, surgeons, or other specialists and thus are more likely to work full-time in an ICU, he said. "From that perspective, why are there only 34 stand-alone programs in internal medicine critical care compared to 134 programs in pulmonary critical care? Maybe that could be addressed in a more efficient way."
Pulmonary critical care medicine programs also could be doing more. Although it’s not well known, the Accreditation Council for Graduate Medical Education (ACGME) allows pulmonary critical care programs every other year to train a fellow who does not want to be certified in pulmonary medicine but only wants to do critical care medicine, Dr. Pastores said. If the programs took advantage of that, the number of full-time critical care providers would increase.
A paper to be published by Dr. Pastores and his colleagues this spring in the journal Critical Care Medicine will propose that the ACGME relax some "very restrictive mandates" on internal medicine–based critical care medicine training programs.
One hurdle requires the critical care medicine program’s primary site to offer at least three out of five key fellowship programs. "That can be very difficult for many of the smaller programs that are not major academic centers, where they may not have things like fellowships in infectious diseases, nephrology, pulmonary, et cetera," he said.