The rapid growth of the elderly population in the United States may create a shortage of critical care physicians in the United States—a shortage that could lead to tens of thousands of potentially preventable deaths in the country's intensive care units, a new federal report warns.
The report has prompted critical care societies to outline solutions and press lawmakers and federal health agencies for greater help in boosting the nation's supply of critical care intensivists.
Policy makers can attack the problem in three ways: by “increasing supply, increasing efficiency, or decreasing the need for intensive care,” said Dr. W. Michael Alberts, president of the American College of Chest Physicians.
With the nation's elderly population rising rapidly, “demand for intensivists will continue to exceed available supply through the year 2020 if current supply and demand trends continue,” according to the report, entitled “The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians.”
The federal Health Resources and Services Administration (HRSA) produced the report for Congress, which asked the agency in 2003 to examine the adequacy of the critical care workforce.
Almost 500,000 people die in ICUs each year, according to the report, and 360,000 of them are not managed by intensivists. If they were, an estimated 54,000 lives could be saved annually, according to a study cited by HRSA researchers (Eff. Clin. Pract. 2000;3:284–9).
Although intensivists currently direct the care of only one-third of critically ill patients, the proportion of patients receiving care under the direction of an intensivist has increased dramatically in recent years.
Increasing the proportion of ICU patients whose care is directed by an intensivist from one-third to a more optimal level of two-thirds would save lives—but it would also push the need for intensivists from 3,100 in 2000 to 4,300 by 2020.
The result: A shortage of about 1,200 intensivists in 2000 could grow to an estimated shortfall of 1,500 in 2020—or 129% above the projected supply.
As demand for critical care specialists grows, so does the burden on existing intensivists—prompting many of them to consider early retirement. More than half of intensivists expect to retire by age 60, and almost a third expect to retire by age 55, according to a report in 2000 by the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS).
Retirement isn't the only factor that may worsen the shortfall. Difficulty attracting physicians to the field, gender issues, and the proportion of international medical graduates (IMGs) could also leave the nation unable to meet its critical care needs. Currently, intensivist fellowship positions are not fully filled, said Dr. Alberts, who is a professor of oncology and medicine at the University of South Florida, Tampa. The number of newly trained critical care medicine fellows per year has actually dropped from 110 in 1998 to 86 in 2004, according to the HRSA report. In fact, less than 1% of U.S. medical school graduates are expected to choose to practice as intensivists.
Although 86% of pulmonologists and critical care physicians are men, a greater proportion of the younger generation of intensivists are women. Because female physicians tend to work fewer hours and retire sooner, the number of hours provided could fall, the report's authors cautioned.
The large proportion of critical care fellows who are international medical graduates may add to the uncertainty. Those IMGs may face visa restrictions that force them out of the United States.
Creation of more critical care specialists won't be easy, the HRSA report acknowledged. “Simple solutions to the critical care workforce problem are not likely to be found in the near future,” the report's authors said.
The rise of intensivist-managed ICUs could help meet some of the unmet demand. Encouraging intensivists and pulmonologists trained in critical care to spend more of their work hours in the ICU might increase supply as well. But the report's authors cautioned that such strategies may require significant financial incentives.
Better management of demand could come as more hospitals use in-house, full-time intensivists to ensure appropriate utilization of critical care services and reduce unnecessary ICU admissions. Improved education regarding end-of-life issues might help physicians and patients make better treatment decisions and potentially reduce the number of days of ICU care.
Organizational changes could improve patient access in a different way, especially in rural areas. “One example is the increased use of electronic ICUs, where specialist physicians and nurses monitor and help treat critically ill patients in widely scattered hospitals,” the authors stated.
To help close the projected shortfall, four critical care societies have outlined their own proposals to increase the efficient use of current critical care resources and boost the supply of intensivists in the future.