Ideas, but no easy way to ease intensivist shortage
The American College of Chest Physicians and the American Association of Critical-Care Nurses have advocated for a "comprehensive approach to improving critical care delivery in the United States" (Chest 2012;142:5), pointing to telemedicine and interdisciplinary strategies to cope with the intensivist shortage rather than endorsing the expedited hospitalist training model.
Internal medicine as pipeline
Besides hospitalists, Dr. Pastores sees greater possibilities from expanding the pipeline of internists into critical care.
"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. Dr. Pastores said that although it's not well known, the ACGME allows pulmonary critical care programs every other year to train a fellow who does not want to be certified in pulmonary medicine but wants only to do critical care medicine. If the programs took advantage of that, the number of full-time critical care providers would increase, he said.
The speakers had no relevant disclosures.
Lori Buckner Farmer contributed to this article.
Dr. Eleanor Summerhill, FCCP, comments: How to address the growing shortfall in board-certified intensivists remains an area of continued debate. Currently, institutions are utilizing telemedicine, physician extenders, and in many instances, hospitalist physicians to fill this gap. At the Society of Critical Care Medicine (SCCM) Critical Care Congress in January 2014, speakers advocated for a number of possible solutions to this problem, largely involving expanding opportunities for further critical care training. These included relaxation of the ACGME mandate requiring that a critical care medicine fellowship's primary training site offer at least three of five key fellowship programs.
Given that there is a significant body of evidence that shows that patients cared for in high-intensity vs. low-intensity intensivist staffing models have reduced mortality and length of stay, going forward it will be important to consider some of these "thinking out of the box" models, while ensuring that alternative training strategies maintain appropriate levels of competency.
