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Editorials: Point and Counterpoint |

Rebuttal From Dr Rubenfeld FREE TO VIEW

Gordon D. Rubenfeld, MD
Author and Funding Information

CORRESPONDENCE TO: Gordon D. Rubenfeld, MD, Program in Trauma, Emergency and Critical Care, Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Ave, Room D108c, Toronto, ON M4N 3M5, Canada


Copyright 2016, . All Rights Reserved.


Chest. 2016;149(3):629-630. doi:10.1016/j.chest.2015.11.028
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I read with interest the argument by Dr Davidson about growing “Little Critical Care” in lieu of some of the options proposed to address the looming critical care physician workforce gap. He argues against reducing demand for intensivist physicians through regionalization, telemedicine, advance practice clinicians, and hospitalists at small hospitals. His points are compelling. By removing intensivists, we take skilled physicians away from the bedside and potentially harm patients. In an inverse of the hospitalist-as-intensivist model, he argues that intensivists should fill the hospitalist gap at these sites. He suggests that “intensively caring” for patients in an ICU by an intensivist provides value even if they are not critically ill. Except for the unexpected dig at health services research methods upon which his arguments rely, I share his passionate advocacy for improved critical care training and innovation. I find myself with very little to rebut. In this US election year of promises, this modest proposal for “intensivists in every hospital” reminds me of the 1928 Republican promise to deliver “a chicken in every pot.” Who can argue with that?

We must skip over whether Dr Davidson’s “Little ICU” model of part-time intensivists who “fill their non-ICU hours with pulmonary, sleep, and some internal medicine consults” actually are providing the intensivist-led critical care that we think the evidence, such as it is, supports. The only fiscal issue he considers are the physician income and critical care revenue impacts on hospital budgets. These are important barriers to restructuring of critical care, and financial incentives can be a powerful force for good or evil. His argument completely ignores the trade-offs of spending money from a limited medical education budget on intensivist training rather than the hospitalists, palliative care, and family physicians that these communities also, and will increasingly, lack. He ignores the fact that the “Little ICUs” will not be able to find nurses because his model will lead to critical care bed growth that will outstrip the nursing and other health-care worker supply. He has not really addressed that even if there are jobs, intensivists may not choose to work in “Little ICUs.” But these limitations pale compared with the effect that this proposal will have on the overall health-care budget in the United States. Projecting future need for critical care services based on current demand will contribute to financially unsustainable growth in medical care costs. There is no question that an aging population will need more intensivists, and geriatricians, internists, surgeons, nurses, and health-care workers in general. The past two editorials do not ignore the future need for intensivists; they are a plea for our field to consider a broader set of solutions and fiscal realities than the status quo Dr Davidson guards.

To close the analogy, and without attributing causality to this retrospective unmatched observation, the unfulfilled Republican promise in 1928 to put a chicken in every pot was followed 12 months later by the Great Depression.

References

Davidson B.L. . Point: Does the US need more intensivist physicians? Yes. Chest. 2016;149:621-625 [PubMed]journal
 
Kahn J.M. .Asch R.J. .Iwashyna T.J. .et al Physician attitudes toward regionalization of adult critical care: a national survey. Crit Care Med. 2009;37:2149-2154 [PubMed]journal. [CrossRef] [PubMed]
 
Center for Workforce Studies Recent studies and reports on physician shortages in the US.  2012;:- [PubMed] American Association of Medical Colleges Washington, DCjournal
 
Robnett M.K. . Critical care nursing: workforce issues and potential solutions. Crit Care Med. 2006;34:S25-S31 [PubMed]journal. [CrossRef] [PubMed]
 
Rabinowitz H.K. .Diamond J.J. .Markham F.W. .Santana A.J. . The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med. 2012;87:493-497 [PubMed]journal. [CrossRef] [PubMed]
 
Neuman P. .Cubanski J. .Damico A. . Medicare per capita spending by age and service: new data highlights oldest beneficiaries. Health Aff (Millwood). 2015;34:335-339 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Rubenfeld G.D. . The myth of the workforce crisis: why the United States does not need more intensivist physicians. Am J Respir Crit Care Med. 2015;191:128-134 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Davidson B.L. . Point: Does the US need more intensivist physicians? Yes. Chest. 2016;149:621-625 [PubMed]journal
 
Kahn J.M. .Asch R.J. .Iwashyna T.J. .et al Physician attitudes toward regionalization of adult critical care: a national survey. Crit Care Med. 2009;37:2149-2154 [PubMed]journal. [CrossRef] [PubMed]
 
Center for Workforce Studies Recent studies and reports on physician shortages in the US.  2012;:- [PubMed] American Association of Medical Colleges Washington, DCjournal
 
Robnett M.K. . Critical care nursing: workforce issues and potential solutions. Crit Care Med. 2006;34:S25-S31 [PubMed]journal. [CrossRef] [PubMed]
 
Rabinowitz H.K. .Diamond J.J. .Markham F.W. .Santana A.J. . The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med. 2012;87:493-497 [PubMed]journal. [CrossRef] [PubMed]
 
Neuman P. .Cubanski J. .Damico A. . Medicare per capita spending by age and service: new data highlights oldest beneficiaries. Health Aff (Millwood). 2015;34:335-339 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Rubenfeld G.D. . The myth of the workforce crisis: why the United States does not need more intensivist physicians. Am J Respir Crit Care Med. 2015;191:128-134 [PubMed]journal. [CrossRef] [PubMed]
 
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