A new ICU paradigm: Intensivists as primary critical care physicians

OUR EXPERIENCE

Our intensivist group has been providing a near-primary-care style of critical care practice for almost 40 years, from its inception in 1977 by one of the authors (A.B.), to our current group of 15 board-certified intensivists. We can easily cite the clinical value of our practice approach, with outcome data showing consistent and better-than-expected Standardized Mortality Ratio accounts from our APACHE IV data (personal communication, Cleveland Clinic Cerner/APACHE IV report), or with reports showing that the presence of a full-time, attending-level, in-house staff physician ensures that patients, surgeons, and consultants have confidence and respect for the care provided. However, we feel that the intangible components are what make our practice a prototype for the PCCP model.

A dedicated team with a low turnover rate

First, we have a team of anesthesiology- and surgery-based intensivists dedicated to ICU practice, with a very low turnover or burnout rate, in contrast to most ICUs in the United States, where intensivists tend to practice part-time (at other times either providing operating-room-based anesthesia or surgical care or working in a pulmonary- or sleep-lab-based practice). We believe this point should not go unstressed: we have a team of physicians who have dedicated their career to working in the ICU full-time, and some have done so in excess of 20 years, even as long as 30 years! It is our opinion that we are able to provide such a highly desirable working environment by a unique daily staffing model that does not utilize the conventional practice style of one intensivist on-call per week.

We also feel that our model dramatically reduces the risk of burnout by permitting our attending intensivists to break up on-call sequences so that there are days on which work in the ICU is not also associated with on-call responsibilities.

A successful fellowship program

Second, we have an extremely successful fellowship program, which began in 1974 when one of the authors (A.B.) advocated the training of anesthesiology residents as intensivists.¹¹ The American Board of Anesthesiology certifies on average 55 candidates per year in critical care medicine, and our program trains about 10% of the physicians applying for certification. In most years, there are actually more candidates for our program than there are available positions, which is atypical for anesthesiology-based critical care training programs. This wealth of young, talented candidates interested in critical care as a career is, again, in contrast to most anesthesiology-based programs, which find it difficult to enroll even one fellow per year.

Critical care programs grounded in anesthesiology typically struggle because of the realities of economics.¹² The payoff of operating-room-based anesthesiology practices generally outshines those in critical care, yet we already have three times as many candidates as there are positions to start our training program in the next 2 years. We feel that candidates are attracted to our program simply because our environment (dedicated staffing, equal clinical footing with surgeons, low burnout rates) is seen as an exciting, positively charged role-modeling atmosphere for young physicians who may have a career interest that involves more than just their original base specialty.

A collegial working relationship

Third, we have a thriving, collegial working relationship—including daily bedside and weekly bioethics rounds with our nursing staff—which has fueled a high degree of professional satisfaction among nurses. This is evidenced by the extremely low turnover rate of nurses (less than 5% per year in the last 5 years) and by national recognition for nursing excellence (Beacon Award for Critical Care Excellence, American Association of Critical Care Nurses) (personal communication, S. Wilson, Nurse Manager). In 2009, the four nurses out of 174 who left did so to further their careers.

While low turnover rates among nurses and award-winning practices are surely a testament to a highly motivated and skilled nursing team, there is no question that a constructive collegiality among the physicians and nurses has provided an environment to allow these positive aspects to flourish.

OVERCOMING ROADBLOCKS

Obviously, although in theory it is easy to proclaim a PCCP paradigm, in reality the roadblocks are many.

For example, standardization of education and credentialing would be an essential hurdle to overcome. The current educational arrangement of the various adult specialties (anesthesiology, internal medicine, surgery), each offering disparate subspecialty critical care training and certification, is deeply rooted in interdisciplinary politics, but without any demonstration of improved patient care.¹³ As described recently by Kaplan and Shaw,¹⁴ an all-encompassing training and credentialing standard for critical care is essential for 21st century medicine and would go a long way toward development of the PCCP paradigm.

Another major roadblock is the shortage of intensivists in the United States.¹³ There are many reasons why physicians opt not to select critical care as a career, such as a non-straight-forward training pathway (as described above), recognition that the 24-hours per day, 7-days-per-week nature of critical care affects lifestyle issues, and inconsistent physician compensation.¹³

However, technological and personnel advances, including the use of electronic (e-ICU)¹⁵ and mid-level practitioner models, have led to creative approaches to extend critical care coverage.¹³

Additionally, the multitude of physician specialty stakeholders and the overall flux of the future of medical care in the United States all would contribute to the difficulties of prioritizing the implementation of the PCCP concept. Also, our practice style—a large intensivist group working in an ostensibly closed surgical ICU in a tertiary-care hospital—is one possible model, as is the even more highly evolved Cleveland Clinic medical ICU, where medical intensivists are already essentially PCCPs. But these models of care may not be generalizable among the local care patterns and medical politics across hospitals or ICUs.

Based on the described successes of our practice model, coupled with evidence in the literature, we have proposed a paradigm shift toward the concept of a PCCP. To be sure, paradigm shifts nearly always require time, effort, and wherewithal. In the end, however, we feel that embracement of the PCCP paradigm would result in a concise, discrete understanding of the role of intensivist, eliminate the specialty’s identity crisis, and ultimately improve patient care.