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Editorials: Point and Counterpoint |

Rebuttal From Dr Davidson FREE TO VIEW

Bruce L. Davidson, MD, MPH, FCCP
Author and Funding Information

CORRESPONDENCE TO: Bruce L. Davidson, MD, MPH, FCCP, 12209 Shorewood Dr SW, Seattle, WA 98146


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(3):628-629. doi:10.1016/j.chest.2015.11.029
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Dr Rubenfeld writes, “Will we need more intensivists? Almost certainly.” Dr Rubenfeld is more thorough than I when refuting postulated intensivist physician estimates. On these two important topics, we agree.

However, he proposes “simple comparative effectiveness evaluations,” an oxymoron. Dr Rubenfeld floats false either-or phrasing, eg, choosing between intensivists or family doctors, that Dr Koshland described (and I cite) in my article. This fallacy, a selectively imposed zero-sum argument for those two training categories ignores other categories such as ever-larger allocations for information technology, imaging, and drug costs. We can afford to train in critical care and family medicine if budgets are set after managing priorities appropriately.

Regarding who should set such priorities, my article provides Dr Koshland’s guidance. Dr Rubenfeld proposes national workforce panels without describing their makeup or how they will ascertain and fill very differing local needs. He reassures there are intensivist leadership opportunities restricting demand for critical care and overseeing nonintensivists. Those chosen to lead vs those doomed to follow…an as-yet opaque pathway to scoring a critical care bed for a patient…We differ greatly on these points. Financial sustainability will require focus on the primary missions, academic and/or clinical, in the way I describe. It is not merely numbers of doctors that matters, it is also what the doctors do.

There should be no doubt that dedicated and capable nurses (without advanced practice training), internists (including second- and third-year medical residents), physician assistants, and other ICU team members can excellently look after critically ill patients. They have been doing so since ICUs existed—but under the care of a supervising ICU-capable physician on call to the bedside. Dr Rubenfeld would subtract bedside intensivist physicians in favor of telemedicine doctors, hospitalists, and nurse practitioners. My article presented the flaws and some undermining financial motivations in this model. The psychic toll on patients and care givers of televised, rather than on-site intensivist availability for a critically ill patient, and the litigation costs of a bad outcome, should worry hospitals considering this approach.

Only badly flawed, retrospective, data-dredging publications dismiss the value of intensivists, comprising unreliable support for withholding and reducing advanced training. Dr Rubenfeld cites Wise et al in asking if we are prepared to acknowledge that hospitalists deliver equivalent care to an intensivist. That article’s hospitalist-managed patients included only 11% on ventilators, compared to 52% on ventilators for intensivist-managed patients. The authors concluded their results “contradict the controversial findings by Levy et al [reference 7 in Dr Rubenfeld’s article] which suggested that ICU patients with intermediate disease acuity have increased hospital mortality when cared for by intensivists versus non-intensivists.” They propose “asking hospitalists to care independently for lower acuity ICU patients—especially non-ventilated patients—while encouraging or requiring intensivist care for higher acuity patients, especially once mechanically ventilated.”

I proposed local intensivist-led, hospital-funded, professionally mandated ICU services. Many don't need 100% board-certified intensivists nor 24-h or 12-h on-site coverage but rather on-call availability at the bedside for admissions and after rounds. Dominant centers, including the academic ones where trainees come from, need to focus on this approach, on role-modeling continuity (rather than 1-2 weeks) of care, and discovery (rather than inference-mining, adjustment-flawed) research into new and better ways to relieve suffering, prevent disability, and postpone death in ICU patients.

References

Rubenfeld G.D. . Counterpoint: Does the US need more intensivist physicians? No. Chest. 2016;149:625-628 [PubMed]journal
 
Davidson B.L. . Point: Does the US need more intensivist physicians? Yes. Chest. 2016;149:621-625 [PubMed]journal
 
Wise K.R. .Akopov V.A. .Williams B.R. Jr..Ido M.S. .Leeper K.V. Jr..Dressler D.D. . Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189 [PubMed]journal. [CrossRef] [PubMed]
 
Levy M.M. .Rapoport J. .Lemeshow S. .Chalfin D.B. .Phillips G. .Danis M. . Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med. 2008;148:801-810 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Rubenfeld G.D. . Counterpoint: Does the US need more intensivist physicians? No. Chest. 2016;149:625-628 [PubMed]journal
 
Davidson B.L. . Point: Does the US need more intensivist physicians? Yes. Chest. 2016;149:621-625 [PubMed]journal
 
Wise K.R. .Akopov V.A. .Williams B.R. Jr..Ido M.S. .Leeper K.V. Jr..Dressler D.D. . Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7:183-189 [PubMed]journal. [CrossRef] [PubMed]
 
Levy M.M. .Rapoport J. .Lemeshow S. .Chalfin D.B. .Phillips G. .Danis M. . Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med. 2008;148:801-810 [PubMed]journal. [CrossRef] [PubMed]
 
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