Editorial
training and we have not (15)? The answers to these questions are undoubtedly complex and involve economics, power, and control. The solutions perhaps should stay focused on why we exist rather than on what discipline we have trained in. I would like to think we have the will to make these changes and the moral imperative to do so. I hope "Somewhere Over the Rainbow" (16) there will be a unified training paradigm for CCM that will welcome individuals from all disciplines and will produce intensivists who can care for the broad spectrum of critically ill and injured patients because we have learned from each other's perspectives. At the end of the yellow brick road, what could be better?
REFERENCES 1. Safar P, Dekornfeld TJ, Pearson JW, et al: The intensive care unit. A three year experience at Baltimore city hospitals. Anaesthesia 1961 ; 16:275-284 2. Safar P, Grenvik A: Organization and physician education in critical care medicine. Anesthesiology 1977; 47:82-95 3. Angus DC, Kelley MA, Schmitz RJ, et al; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS): Caring for the critically ill patient. 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; 284:2762-2770 4. Health Resources and Services Administration Report to Congress: The Critical Care Workforoe: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed July 25. 2013
5. Barnato AE, Kahn JM, Rubenfeld GD, et al: Prioritizing the organization and management of intensive care services in the United States: The PrOMIS Conference. Crit Care Med 2007; 35:1003-1011 6. Tisherman SA, Kaplan L, Gracias VH, et al: Providing care for critically ill surgical patients. Challenges and recommendations. JAMA Surg 2013; 148:669-674 7 Embriaco N, Azoulay E, Barrau K, et al: High level of burnout in intensivists: Prevalence and associated factors. Am J Respir Crit Care Med 2007; 175:686-692. Erratum in: Am J Respir Crit Care Med 2007; 175:1209-1210 8. Merlani P, Verdón M, Businger A, et al; STRESI-f Group: Burnout in ICÜ caregivers: A multicenter study of factors associated to centers. Am J Respir Crit Care Med 2011 ; 184:1140-1146 9. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2754-2761 10. Kaplan LJ, Shaw AD: Standards for education and oredentialing in critical care medicine. JAMA 2011 ; 305:296-297 11. Garland A, Gershengorn HB: Staffing in ICUs: Physicians and alternative staffing models. Chest 2013; 143:214-221 12. Cousin DB, Barrett H, Bion JF, et al: Crisis in critical care: Training and certifying future intensivists. Curr Opin Anaesthesiol 2006; 19:107-110 13. Kozar RA, Shackford SR, Cocanour CS: Challenges to the care cf the critically ill: Novel staffing paradigms. J Trauma 2008; 64:366-370 14. Fessier HE: Undergraduate medical education in critical care. Crit Care Med 201 2; 40:3065-3069 15. CoBaTrlCE Collaboration: The educational environment for training in intensive care medicine: Structures, processes, outcomes and challenges in the European region. Intensive Care Med 2009; 35:1575-1583 16. Garland J: Over the Rainbow (Music by Arlen H and Lyrics by Harburg EY). MGM Production, 1939
More, Please' Jonathan E. Sevransky, MD, MHS Division of Pulmonary, Allergy, and Critical Care Emory Cenfer for Critical Care Emory University Aflanfa, GA Andrew Shorr, MD, MPH Division of Pulmonary and Critical Care Medicine Washingfon Hospifal Cenfer Washingfon, DC
•See also p. 2754. Key Words: administration; critical care; training Dr. Sevransky lectured for various organizations. His institution received grant support from Abbott Laboratories. Dr. Shorr consulted and received grant support from Astellas, Bayer, Cubist, Pfizer, Forest, Trius, and Theravance. He lectured for Astellas and Pfizer. Copyright © 2013 by the Society of Critical Care Medicine and Lippinoott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182a1208c
2828
www.ccmjoumal.org
Plus ça change, plus c'est la même chose. —Alphonse Karr The Times They Are A-Changin'. —Bob Dylan
I
n many ways, intensivists are the victims of their own success. We have convinced hospitals, payers, and, in some instances, patients that life-threatening ulness or injury requires specialized care from a team of trained professionals. This team includes critical care nurses, respiratory therapists, pharmacists, and physicians trained and devoted to critical care medicine. In response to evidence suggesting that critical care physicians foster improved adherence to process measures and enhanced patient outcomes, many institutions have shifted to ICU staffing models that require intensivist-driven care (1). However, the need for trained intensivists far outweighs the number produced (2). Many potential options exist to solve this supply and demand disparity and most focus on addressing the issue of "supply." Reliance on hospitalists, employment of nurse practitioner and physician assistants, and the development of telemedicine represent potential models for providing care to critically ill and injured patients (3-5). Each of these options has been used with varying degrees of success (3-5). December 2013 • Volume 41 • Number 1 2
Editorial
In this issue of Critical Care Medicine, Halpern et al (6) offer some additional solutions to the imbalance between the number of intensivists produced and intensivists needed. They suggest increasing the number of undiflèrentiated medical critical care physicians produced by increasing the number of 2-year training slots that would be made available to graduates of traditional 3-year internal medicine programs. To achieve this goal, they suggest that the training program requirements be relaxed to allow training in community hospitals (where the majority of critical care is delivered) and that members of other certified disciplines, such as anesthesia and emergency medicine, be allowed to be named as core clinical faculty (6). Additionally, they suggest that early exposure to critical care and improved salaries for intensivists may increase the number of physicians who select this specialty (6). Some of the analysis presented by Halpern et al (6) is clearly controversial. For example, they posit that medical critical care physicians are the ones best suited to care for most critically ill patients. This is, of course, an assertion for which there is little evidence. What type of training and background best prepares a physician to care for critically ill patients remains uncertain. It stands to reason that trained clinicians who practice critical care exclusively will provide superior critical care coverage than those who spend some time doing alternate clinical tasks, such as operating room time or pulmonary medicine. Alternatively, ongoing non-ICU exposures provide a broader depth and background that could enhance the care of the critically ill patient. Additionally, it is not clear that the clinical Hfespan of physicians who practice critical care exclusively is greater than those who practice primarily critical care. There exist other potential means for reconciling the imbalance between the demand and supply for intensivist care. For example, some have proposed regionalizing select high resource care in centers as done with trauma centers (7). Limiting the number of centers that perform selected procedures with both an extensive learning curve and high capital requirements may allow better use of limited physician resources. In addition, broader use of palliative care for those patients in which such care is appropriate may reduce the number of unnecessary critical care admissions (8). In other words, it is crucial to not only address the supply half of the equation but also deal with the issue of demand. The number of patients who die while receiving intensive care in the United States is substantially higher than that in other developed countries (9). Providing more access to palliative care services could reduce the number of admissions to ICUs and, as a result, help constrain demand for the number of critical care physicians. Critical care remains a costly high-tech enterprise. It is clear that we need more clinicians to care for these patients. Although we are doubtful that the solutions proposed by Halpern et al (6) will completely solve the problem, their analysis helps to focus a discussion and debate that we as a profession need to be having.
Critical Care Medicine
Other fields have taken on the burden of studying which type of physician provides better care for patients. For example, there are now studies comparing whether patients with coronary artery disease should be treated by an invasive cardiologist versus a cardiothoracic surgeon (10). Properly done studies systematically examining which model of critical care delivery proves most effective and cost efficient should drive the production and training of the clinicians needed to staff ICUs. The recent analyses refuting the need for 24-hour ICU attending coverage represent an example of the type studies required (11, 12). Before we ask hospitals and governmental funding agencies to pay for additional ICU staffing, we ought to first determine what types of critical care teams (including intensivists) provide the most efficient and patient centric care.
REFERENCES 1. Pronovost PJ, Angus DC, Dormán T, et al: Physician staffing patterns and ciinicai outcomes in critically ill patients: A systematic review. JAMA 2002; 288:2151 -21 62 2. Angus DC, Kelley MA, Schmitz RJ, et al; Committee on Manpower for Pulmonary and Critical Care Sooieties (CCMPACCS): Caring for the critically ill patient. Current and projected workforce requirements tor care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA 2000; 284:2762-2770 3. Lilly CM, Cody S, Zhao H, et al; University of Massachusetts Memorial Critical Care Operations Group: Hospital mortality, length of stay, and preventable complications among oritically ill patients before and after teie-ICU reengineering of critical care processes. JAMA 2011 ; 305:2175-2183 4. Siegal EM, Dressier DD, Dichter JR, et al: 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; 40:1952-1956 5. Gershengorn HB, Wunsch H, Wahab R, et al: Impact of nonphysician staffing on outcomes in a medical ICU. Chest 2011 ; 139:1347-1353 6. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2764-2761 7 Nguyen YL, Kahn JM, Angus DC: Reorganizing adult critical care delivery: The role of regionalization, telamedicine, and community outreach. Am J Respir Crit Care Med 2010; 181:1164-1169 8. Truog RD: Palliative care in the ICU: Lots of questions, few answers. Crit Care Wed 2013; 41:1568-1569 9. Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group: Use of intensive care at the end of lite in the United States: An epidemiologic study. Crit Care Med 2004; 32:638-643 10. Hannan EL, Wu C, Walford G, et al: Drug-eluting stents vs. coronaryartery bypass grafting in multivessel coronary disease. N Engi J Med 2008; 358:331-341 11. Wallace DJ, Angus DC, Barnato AE, et al: Nighttime intensivist staffing and mortality among critically ill patients. N Engi J Med 2012; 366:2093-2101 12. Kerlin MP, Small DS, Cooney E, et al: A randomized trial ot nighttime physician staffing in an intensive care unit. N Engi J Med 2013; 368:2201-2209
www.ccmjournal.org
2829
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
training and we have not (15)? The answers to these questions are undoubtedly complex and involve economics, power, and control. The solutions perhaps should stay focused on why we exist rather than on what discipline we have trained in. I would like to think we have the will to make these changes and the moral imperative to do so. I hope "Somewhere Over the Rainbow" (16) there will be a unified training paradigm for CCM that will welcome individuals from all disciplines and will produce intensivists who can care for the broad spectrum of critically ill and injured patients because we have learned from each other's perspectives. At the end of the yellow brick road, what could be better?
REFERENCES 1. Safar P, Dekornfeld TJ, Pearson JW, et al: The intensive care unit. A three year experience at Baltimore city hospitals. Anaesthesia 1961 ; 16:275-284 2. Safar P, Grenvik A: Organization and physician education in critical care medicine. Anesthesiology 1977; 47:82-95 3. Angus DC, Kelley MA, Schmitz RJ, et al; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS): Caring for the critically ill patient. 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; 284:2762-2770 4. Health Resources and Services Administration Report to Congress: The Critical Care Workforoe: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108-81. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed July 25. 2013
5. Barnato AE, Kahn JM, Rubenfeld GD, et al: Prioritizing the organization and management of intensive care services in the United States: The PrOMIS Conference. Crit Care Med 2007; 35:1003-1011 6. Tisherman SA, Kaplan L, Gracias VH, et al: Providing care for critically ill surgical patients. Challenges and recommendations. JAMA Surg 2013; 148:669-674 7 Embriaco N, Azoulay E, Barrau K, et al: High level of burnout in intensivists: Prevalence and associated factors. Am J Respir Crit Care Med 2007; 175:686-692. Erratum in: Am J Respir Crit Care Med 2007; 175:1209-1210 8. Merlani P, Verdón M, Businger A, et al; STRESI-f Group: Burnout in ICÜ caregivers: A multicenter study of factors associated to centers. Am J Respir Crit Care Med 2011 ; 184:1140-1146 9. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2754-2761 10. Kaplan LJ, Shaw AD: Standards for education and oredentialing in critical care medicine. JAMA 2011 ; 305:296-297 11. Garland A, Gershengorn HB: Staffing in ICUs: Physicians and alternative staffing models. Chest 2013; 143:214-221 12. Cousin DB, Barrett H, Bion JF, et al: Crisis in critical care: Training and certifying future intensivists. Curr Opin Anaesthesiol 2006; 19:107-110 13. Kozar RA, Shackford SR, Cocanour CS: Challenges to the care cf the critically ill: Novel staffing paradigms. J Trauma 2008; 64:366-370 14. Fessier HE: Undergraduate medical education in critical care. Crit Care Med 201 2; 40:3065-3069 15. CoBaTrlCE Collaboration: The educational environment for training in intensive care medicine: Structures, processes, outcomes and challenges in the European region. Intensive Care Med 2009; 35:1575-1583 16. Garland J: Over the Rainbow (Music by Arlen H and Lyrics by Harburg EY). MGM Production, 1939
More, Please' Jonathan E. Sevransky, MD, MHS Division of Pulmonary, Allergy, and Critical Care Emory Cenfer for Critical Care Emory University Aflanfa, GA Andrew Shorr, MD, MPH Division of Pulmonary and Critical Care Medicine Washingfon Hospifal Cenfer Washingfon, DC
•See also p. 2754. Key Words: administration; critical care; training Dr. Sevransky lectured for various organizations. His institution received grant support from Abbott Laboratories. Dr. Shorr consulted and received grant support from Astellas, Bayer, Cubist, Pfizer, Forest, Trius, and Theravance. He lectured for Astellas and Pfizer. Copyright © 2013 by the Society of Critical Care Medicine and Lippinoott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182a1208c
2828
www.ccmjoumal.org
Plus ça change, plus c'est la même chose. —Alphonse Karr The Times They Are A-Changin'. —Bob Dylan
I
n many ways, intensivists are the victims of their own success. We have convinced hospitals, payers, and, in some instances, patients that life-threatening ulness or injury requires specialized care from a team of trained professionals. This team includes critical care nurses, respiratory therapists, pharmacists, and physicians trained and devoted to critical care medicine. In response to evidence suggesting that critical care physicians foster improved adherence to process measures and enhanced patient outcomes, many institutions have shifted to ICU staffing models that require intensivist-driven care (1). However, the need for trained intensivists far outweighs the number produced (2). Many potential options exist to solve this supply and demand disparity and most focus on addressing the issue of "supply." Reliance on hospitalists, employment of nurse practitioner and physician assistants, and the development of telemedicine represent potential models for providing care to critically ill and injured patients (3-5). Each of these options has been used with varying degrees of success (3-5). December 2013 • Volume 41 • Number 1 2
Editorial
In this issue of Critical Care Medicine, Halpern et al (6) offer some additional solutions to the imbalance between the number of intensivists produced and intensivists needed. They suggest increasing the number of undiflèrentiated medical critical care physicians produced by increasing the number of 2-year training slots that would be made available to graduates of traditional 3-year internal medicine programs. To achieve this goal, they suggest that the training program requirements be relaxed to allow training in community hospitals (where the majority of critical care is delivered) and that members of other certified disciplines, such as anesthesia and emergency medicine, be allowed to be named as core clinical faculty (6). Additionally, they suggest that early exposure to critical care and improved salaries for intensivists may increase the number of physicians who select this specialty (6). Some of the analysis presented by Halpern et al (6) is clearly controversial. For example, they posit that medical critical care physicians are the ones best suited to care for most critically ill patients. This is, of course, an assertion for which there is little evidence. What type of training and background best prepares a physician to care for critically ill patients remains uncertain. It stands to reason that trained clinicians who practice critical care exclusively will provide superior critical care coverage than those who spend some time doing alternate clinical tasks, such as operating room time or pulmonary medicine. Alternatively, ongoing non-ICU exposures provide a broader depth and background that could enhance the care of the critically ill patient. Additionally, it is not clear that the clinical Hfespan of physicians who practice critical care exclusively is greater than those who practice primarily critical care. There exist other potential means for reconciling the imbalance between the demand and supply for intensivist care. For example, some have proposed regionalizing select high resource care in centers as done with trauma centers (7). Limiting the number of centers that perform selected procedures with both an extensive learning curve and high capital requirements may allow better use of limited physician resources. In addition, broader use of palliative care for those patients in which such care is appropriate may reduce the number of unnecessary critical care admissions (8). In other words, it is crucial to not only address the supply half of the equation but also deal with the issue of demand. The number of patients who die while receiving intensive care in the United States is substantially higher than that in other developed countries (9). Providing more access to palliative care services could reduce the number of admissions to ICUs and, as a result, help constrain demand for the number of critical care physicians. Critical care remains a costly high-tech enterprise. It is clear that we need more clinicians to care for these patients. Although we are doubtful that the solutions proposed by Halpern et al (6) will completely solve the problem, their analysis helps to focus a discussion and debate that we as a profession need to be having.
Critical Care Medicine
Other fields have taken on the burden of studying which type of physician provides better care for patients. For example, there are now studies comparing whether patients with coronary artery disease should be treated by an invasive cardiologist versus a cardiothoracic surgeon (10). Properly done studies systematically examining which model of critical care delivery proves most effective and cost efficient should drive the production and training of the clinicians needed to staff ICUs. The recent analyses refuting the need for 24-hour ICU attending coverage represent an example of the type studies required (11, 12). Before we ask hospitals and governmental funding agencies to pay for additional ICU staffing, we ought to first determine what types of critical care teams (including intensivists) provide the most efficient and patient centric care.
REFERENCES 1. Pronovost PJ, Angus DC, Dormán T, et al: Physician staffing patterns and ciinicai outcomes in critically ill patients: A systematic review. JAMA 2002; 288:2151 -21 62 2. Angus DC, Kelley MA, Schmitz RJ, et al; Committee on Manpower for Pulmonary and Critical Care Sooieties (CCMPACCS): Caring for the critically ill patient. Current and projected workforce requirements tor care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA 2000; 284:2762-2770 3. Lilly CM, Cody S, Zhao H, et al; University of Massachusetts Memorial Critical Care Operations Group: Hospital mortality, length of stay, and preventable complications among oritically ill patients before and after teie-ICU reengineering of critical care processes. JAMA 2011 ; 305:2175-2183 4. Siegal EM, Dressier DD, Dichter JR, et al: 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; 40:1952-1956 5. Gershengorn HB, Wunsch H, Wahab R, et al: Impact of nonphysician staffing on outcomes in a medical ICU. Chest 2011 ; 139:1347-1353 6. Halpern NA, Pastores SM, Oropello JM, et al: Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty. Crit Care Med 2013; 41:2764-2761 7 Nguyen YL, Kahn JM, Angus DC: Reorganizing adult critical care delivery: The role of regionalization, telamedicine, and community outreach. Am J Respir Crit Care Med 2010; 181:1164-1169 8. Truog RD: Palliative care in the ICU: Lots of questions, few answers. Crit Care Wed 2013; 41:1568-1569 9. Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group: Use of intensive care at the end of lite in the United States: An epidemiologic study. Crit Care Med 2004; 32:638-643 10. Hannan EL, Wu C, Walford G, et al: Drug-eluting stents vs. coronaryartery bypass grafting in multivessel coronary disease. N Engi J Med 2008; 358:331-341 11. Wallace DJ, Angus DC, Barnato AE, et al: Nighttime intensivist staffing and mortality among critically ill patients. N Engi J Med 2012; 366:2093-2101 12. Kerlin MP, Small DS, Cooney E, et al: A randomized trial ot nighttime physician staffing in an intensive care unit. N Engi J Med 2013; 368:2201-2209
www.ccmjournal.org
2829
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
