The growing intensivist shortage is challenging hospitals’ ability to care for critically ill patients. Despite numerous recommendations that intensivists manage critically ill adults, the majority of American hospitals cannot meet this standard. As a consequence, hospitalists have become de facto intensivists in many hospitals, with 75% reporting that they practice in the ICU. While legitimate concerns have been raised whether hospitalists are uniformly qualified to practice in the ICU, the issue has become moot at many hospitals where intensivists are either in short supply or entirely absent.
Efforts are needed to ensure that hospitalists manage critically ill patients safely, effectively, and seamlessly. In the Journal of Hospital Medicine and Critical Care Medicine, the Society of Hospital Medicine and the Society of Critical Care Medicine co-published a position paper on training the hospitalist workforce to address the intensivist shortage. In this paper, we discussed the potential value of hospitalists in the ICU and the importance of enhancing hospitalists’ skills to provide critical care services.
Adding Value & Enhancing Skills of Hospitalists
Hospital medicine and critical care medicine share similar structures, competencies, and values, positioning hospitalists as a logical solution to the intensivist shortage. Many of the competencies needed for practicing critical care medicine are encompassed in internal medicine training as well as in core competencies in hospital medicine. The ideology and mechanics of high-performing hospitalist and intensivist programs are similar, yet despite these commonalities, hospitalists remain largely untapped as a potential source of new intensivists.
Exploring Alternative Critical Care Models
With no solution to the intensivist shortage in sight, alternative critical care delivery models are needed. We proposed a 1-year critical care fellowship track for experienced internal medicine hospitalists. Although critical care medicine is a 2-year fellowship, only 1 year of clinical rotations is required for board eligibility. Furthermore, a 1-year critical care training track already exists for other medical specialists and should be relevant and available to experienced hospitalists as well. Bringing qualified hospitalists into the critical care workforce through rigorous sanctioned and accredited 1-year training programs could open a new intensivist training pipeline. It can also offer more critically ill patients the benefit of providers who are unequivocally qualified to care for them.
Thinking Outside the Box to Alleviate the Shortage
The key is for hospitals, clinicians, and other key constituents to think outside the box when developing strategies to address the intensivist shortage. Rigorously training hospitalists as intensivists could dramatically alleviate some of the burden and should be part of a broader initiative to reform critical care training through a unified, cross-disciplinary approach to developing an intensivist workforce.
Readings & Resources (click to view)
Siegal EM, Dressler 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. J Hosp Med. 2012;7:359-364. Available at: http://www.medscape.com/viewarticle/768430.
Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: a report from the profession. Chest. 2004;125:1514-1517.
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Mayglothing JA, Gunnerson KJ, Huang DT. Current practice, demographics and trends of critical care trained emergency physicians in the United States. Acad Emer Med. 2010;17:325-329.
Murin S. Hospitalists in the intensive care unit: an intensivist perspective. The Hospitalist. 1999;3:5.
Levy MM, Rapoport J, Lemeshow S, et al. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med. 2008; 148:801-809.
Rubenfeld GD, Angus DC. Are intensivists safe? Ann Int Med. 2008; 148:877-879.