Shortage of intensive care specialists in the United States: recent insights and proposed solutions - Critical Care Science (CCS)
Despite well-publicized projections of an impending and actual intensivist workforce crisis in the United States from critical care societies and the federal government for over a decade,(,) there continues to be a nationwide shortage of intensivists. Others, however, contend that workforce models, which base demand projections on intensive care unit (ICU) admission rather than true critical illness, substantially overstate the workforce gap.() We believe that before arguing about the “real” or “imagined” intensivist shortage, there are several fundamental issues to address. First, it is important to agree on a definition of an intensivist. High quality practice and credible team leadership of critical care medicine (CCM) should require the intensivist to devote 100% effort to critical care. Unfortunately, this comprises a small fraction of US practitioners and is predominantly limited to academic medical centers with Accredited Council for Graduate Medical Education (ACGME)-accredited fellowship programs. Because the vast majority of adult intensivists are actually part-time practitioners based in pulmonary medicine, operating rooms (surgeons/anesthesiologists), or emergency medicine, the bulk of CCM board certificates are allocated to part-time physicians;() thus, the shortage of full-time intensivists is most likely 5-10 times more pronounced. To us, this reflects a failure of national advocacy by the critical care organizations and branding of the CCM specialty. If we hope to improve the impact of CCM, we must first acknowledge this national failure and advocate for more funding and political support for our critical care societies and give credit to intensivists dedicated to full-time clinical and academic CCM practice.
Second, there is lack of national and local planning for the proper number and ratio of ICU and progressive/stepdown care beds.() Kahn and Rubenfeld correctly highlight that the real fraction of critically ill patients in US ICUs may be closer to 40 – 60%,() with the other patients remaining in the ICUs due to political pressures, failure of throughput and prompt appropriate discharge, or reluctance to discharge patients from ICUs at night. Because nursing ratios usually define the level of care and comprise the majority of fixed costs in these ICUs, a huge cost saving and amelioration of the nursing shortage may be easily achieved by a firm definition of an ICU bed, rather than closing ICU beds.
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Despite well-publicized projections of an impending and actual intensivist workforce crisis in the United States from critical care societies and the federal government for over a decade,(,) there continues to be a nationwide shortage of intensivists. Others, however, contend that workforce models, which base demand projections on intensive care unit (ICU) admission rather than true critical illness, substantially overstate the workforce gap.() We believe that before arguing about the “real” or “imagined” intensivist shortage, there are several fundamental issues to address. First, it is important to agree on a definition of an intensivist. High quality practice and credible team leadership of critical care medicine (CCM) should require the intensivist to devote 100% effort to critical care. Unfortunately, this comprises a small fraction of US practitioners and is predominantly limited to academic medical centers with Accredited Council for Graduate Medical Education (ACGME)-accredited fellowship programs. Because the vast majority of adult intensivists are actually part-time practitioners based in pulmonary medicine, operating rooms (surgeons/anesthesiologists), or emergency medicine, the bulk of CCM board certificates are allocated to part-time physicians;() thus, the shortage of full-time intensivists is most likely 5-10 times more pronounced. To us, this reflects a failure of national advocacy by the critical care organizations and branding of the CCM specialty. If we hope to improve the impact of CCM, we must first acknowledge this national failure and advocate for more funding and political support for our critical care societies and give credit to intensivists dedicated to full-time clinical and academic CCM practice.
Second, there is lack of national and local planning for the proper number and ratio of ICU and progressive/stepdown care beds.() Kahn and Rubenfeld correctly highlight that the real fraction of critically ill patients in US ICUs may be closer to 40 - 60%,() with the other patients remaining in the ICUs due to political pressures, failure of throughput and prompt appropriate discharge, or reluctance to discharge patients from ICUs at night. Because nursing ratios usually define the level of care and comprise the majority of fixed costs in these ICUs, a huge cost saving and amelioration of the nursing shortage may be easily achieved by a firm definition of an ICU bed, rather than closing ICU beds.
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