Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery

Objective 3: Assessing Interest in Critical Care Education

More than 85% of respondents indicated interest in obtaining additional critical care training and some form of certification short of fellowship training. Preferred modes of content delivery included courses or precourses at national meetings, academies, or online modules. Hospitalists in smaller communities indicated preference for online resources.

This survey of a large national cohort of hospitalists from diverse practice settings validates previous studies suggesting that hospitalists deliver critical care services, most notably in community and rural hospitals.¹³ A substantial subset of our respondents represented rural practice settings, which allowed us to compare rural and nonrural hospitalists as well as those practicing in academic and nonacademic settings. In assessing both the objective services that hospitalists provided as well as their subjective perceptions of how they practiced, we could correlate factors associated with the sense of practicing beyond one’s skill or feeling inadequately supported by board-certified intensivists.

More than a third of responding hospitalists who practiced in the ICU reported that they practiced beyond their self-perceived skill level, and almost three-fourths indicated that they practiced without consistent or adequate board-certified intensivist support. Rural and nonacademic hospitalists were far more likely to report delivering critical care beyond their comfort level and having insufficient board-certified intensivist support.

Calls for board-certified intensivists to deliver critical care to all critically ill patients do not reflect the reality in many American hospitals and, either by intent or by default, hospitalists have become the major and often sole providers of critical care services in many hospitals without robust intensivist support. We suspect that this phenomenon has been consistently underreported in the literature because academic hospitalists generally do not practice critical care.¹⁵

Many potential solutions to the intensivist shortage have been explored. Prior efforts in the United States have focused largely on care standardization and the recruitment of more trainees into existing critical care training pathways.¹⁶ Other countries have created multidisciplinary critical care training pathways that delink critical care from specific subspecialty training programs.¹⁷ Another potential solution to ensure that critically ill patients receive care from board-certified intensivists is to regionalize critical care such that the sickest patients are consistently transferred to referral centers with robust intensivist staffing.^1,18 While such an approach has been effectively implemented for trauma patients⁷, it has yet to materialize on a systemic basis for other critically ill cohorts. Moreover, our data suggest that hospitalists who attempt to transfer patients to higher levels of critical care find doing so burdensome and difficult.

Our surveyed hospitalists overwhelmingly expressed interest in augmenting their critical care skills and knowledge. However, most existing critical care educational offerings are not optimized for hospitalists, either focusing on very specific skills or knowledge (eg, procedural techniques or point-of-care ultrasound) or providing entry-level or very foundational education. None of these offerings provide comprehensive, structured training schemas for hospitalists who need to evolve beyond basic critical care skills to manage critically ill patients competently and consistently for extended periods of time.

Our study has several limitations. First, we estimate that about 10% of invited participants responded to this survey, but as respondents could forward the survey via professional networks, this is only an estimate. It is possible but unlikely that some respondents could have completed the survey more than once. Second, because our analysis identified only associations, we cannot infer causality for any of our findings. Third, the questionnaire was not designed to capture the acuity threshold at which point each respondent would prefer to transfer their patients into an ICU setting or to another institution for assistance in critical care management. We recognize that definitions and perceptions of patient acuity vary markedly from one hospital to the next, and a patient who can be comfortably managed in a floor setting in one hospital may require ICU care in a smaller or less well-resourced hospital. Practice patterns relating to acuity thresholds could have a substantial impact both on critical care patient volumes and on provider perceptions and, as such, warrant further study.

Finally, as respondents participated voluntarily, our sample may have overrepresented hospitalists who practice or are interested in critical care, thereby overestimating the scope of the problem and hospitalists’ interest in nonfellowship critical care training and certification. However, this seems unlikely given that, relative to SHM’s annual survey, we overrepresented hospitalists from academic and large community medical centers who generally provide less critical care than other hospitalists.¹³ Provided that roughly 85% of the estimated 50,000 American hospitalists practice outside of academic medical centers,¹³ perhaps as many as 37,000 hospitalists regularly deliver care to critically ill patients in ICUs. In light of the evolving intensivist shortage,^4,5 this number seems likely to continue to grow. Whatever biases may exist in our sample, it is evident that a substantial number of ICU patients are managed by hospitalists who feel unprepared and undersupported to perform the task.

Without a massive and sustained increase in the number of board-certified intensivists or a systemic national plan to regionalize critical care delivery, hospitalists will continue to practice critical care, frequently with inadequate knowledge, skills, or intensivist support. Fortunately, these same hospitalists appear to be highly interested in augmenting their skills to care for their critically ill patients. The HM and critical care communities must rise to this challenge and help these providers deliver safe, appropriate, and high-quality care to their critically ill patients.