As training evolves, there will be practical issues of credentialing. Currently, a general-IM-trained hospitalist is required to complete a two-year fellowship in critical care to be a specialist. Interestingly, if one’s residency training is in surgery, anesthesia, or rheumatology, that physician requires only one additional year in critical care to become eligible for added/special qualifications in critical-care medicine. What, precisely, is the carryover of the longer residency experience that makes it possible to attain competency in critical care in half the training time?
There also is the risk that we will create a workforce that includes the intensivist-lite—someone who does not have complete, recognized training in critical care but has more than the typical hospitalist, and is perceived as “better than having no intensivist.” Is this in the best interest of our patients or our discipline?
Supply Solutions
There are other approaches to the workforce challenge beyond asking hospitalists to step away from practice for an additional year or two of training. As in other aspects of the hospital workforce, it is time to examine alternative deployment of the entire healthcare team. If intensivists and hospitalists are in limited supply, we need to revisit their roles and further look for opportunities to engage acute-care nurse practitioners, physician assistants, RNs, and others on the healthcare team to meet the expanding needs of our patients and our hospitals.
Another strategy would include regionalization of healthcare in population centers with multiple hospitals. In Orange County, Calif., where I live, there are 33 hospitals for 3 million people, each with some form of an ICU. Is it time to set standards of coverage and expertise so that 10 to 15 hospitals can provide a fully staffed ICU, and the other hospitals refer their most-acute patients rather than be stretched to staff their ICUs at a time of workforce shortages? Is it time to do what we did with trauma centers and set various levels of care so that not every hospital can or should be doing the most intense and costly level of care?
SHM, HM, and, most importantly, hospitalists find themselves in the midst of this growing problem. We must be part of the solution.
It is important to recognize the significant variability in the intensivist skill sets that individual hospitalists and HM groups currently possess; the variance creates hurdles in being able to step up and fill the critical-care gap. I’ve heard about hospitalists pausing their practices to obtain additional training in critical care. Hospitals across America are (or soon will be) scrambling to integrate their hospitalists and intensivists to maximize coverage and expertise. SHM has noticed an increased demand on hospitalists to increase knowledge and skills so they can extend the local coverage of critically ill patients.
It is time for SHM to clearly understand how this sea change is affecting you professionally and personally, because you practice on the frontlines of our nation’s hospitals.
It is time for SHM to engage our colleagues in the ICU—critical-care physicians and their professional societies—to understand their perspective and initiatives on this growing crisis.
It is time for SHM to engage medical educators in residency and fellowship training to explore potential changes in the curriculum—changes aimed at young physicians proceeding through their training that yield hospital-based physicians better prepared to enter the hospital environment of the 21st century.
And SHM may need to engage the boards and other credentialing bodies to look for flexibility that will reflect today’s realities, attract the best-trained physicians to care for the most-acutely-ill patients, and protect our patients by demanding expertise and training at the most appropriate levels. TH