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Editorials: Point and Counterpoint |

POINT: Does the United States Need More Intensivist Physicians? Yes FREE TO VIEW

Bruce L. Davidson, MD, MPH, FCCP
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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):621-625. doi:10.1016/j.chest.2015.11.030
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A January 2015 article, “The Myth of the Workforce Crisis: Why the US Does Not Need More Intensivist Physicians,” stated expanding the intensivist supply was not practical and possibly harmful, and proposed alternatives to address “deficient quality and excess spending”: (1) nonphysician providers for ICU patients; (2) ICU telemedicine instead of an intensivist at the bedside; and (3) regionalization, ie, routinely sending the sickest ICU patients to “centers of excellence.” To decrease ICU bed demand, the authors proposed implicit rationing (restricting ICU beds to force internal triage) and state Certificate of Need laws to restrict ICU beds by decree. They claimed additional intensivists would not work where they were needed and that critical care medicine is not a popular fellowship, in part because of comparatively low reimbursement.

In my view, current shortages at various hospitals mandate providing more intensivists. Qualitatively, an argument to reduce numbers of physicians with advanced training, skills, and experience in a complicated high-mortality and morbidity field seems wrong. Quantitatively, there is neither expert consensus nor accepted evidence regarding how many ICU doctors are enough for the United States's various regions of populations unequally distributed with respect to advanced age and underlying illness. Experts estimating US physician requirements obtain quite different results, depending upon the established methodology used. Domestic epidemics such as HIV, SARS, MERS, and Ebola, requiring intensivists to save lives, are not predictable. Having continually practiced some ICU medicine since completing training in 1983 and having passed the American Board of Internal Medicine examining process for Critical Care when first offered in 1987, and at subsequent 10-year intervals in 1997 and 2007, I present why the United States needs more locally-based physician intensivists, describe how pursuit of revenue has undermined the mission of nationwide critical care improvement, and suggest how to correct the problematic trend that would concentrate money, power, and staffing in dominant hospital systems instead of creating safe systems for optimizing care in communities where the patients are found.

Advocating for nonphysician providers, ICU telemedicine, and transferring patients out of smaller hospital ICUs to “centers of excellence” (implicit disparagement of other physician-associated centers) all focus on establishing dominant institutions as the solution to the intensivist-related resource limitation that smaller and more remote hospitals face. A detailed listing of this paradigm’s flaws and harms is in Table 1., One coauthor of the January 2015 proposal published second thoughts about telemedicine 4 months later: “Whereas some [ICU telemedicine] programs substantially reduce mortality, others have little or no impact. Without clear evidence regarding when and where telemedicine is most effective, we risk wasting scarce health care resources on ineffective programs.” Personally serving as the physician member of Pennsylvania’s Health Facility Hearing Board from 1992 to 1996, I saw repeated failures of the Certificate of Need statute. The regionalization model can be manipulated to focus on revenue. As one colleague described his own academic dominant institution to me, “No longer is it ‘No margin, no mission’; instead, the margin is the mission.” Moreover, not even considering the educational legitimacy of a tuition-collecting graduate school of medicine switching professors for its students every 1 or 2 weeks, foisting this frequent rotation off-service of attending intensivists is a dubious practice for patients from smaller nontraining institutions and unnecessarily interrupts continuity of care.

Table Graphic Jump Location
Table 1 Flaws and Harms of Proposed Dominant Institution Paradigm for Critical Care

NP = nurse practitioner; PA = physician assistant.

The specifics of the substantial incentive for owning critical care billing are presented in Table 2. Dominating this revenue and wresting it from local hospitals and their pulmonary-intensivist physician teams can be an irresistible temptation for dominant institutions. One academic dominant institution critical care department’s website boasts it built a hospitalist business at outlying hospitals that is providing 24% of department billings (Fig 1), absorbing the patients of and displacing local internists and pulmonologists as their inpatient rounding and consultation revenue shrank away—unless they left or chose the path of being conscripted physicians. That “dominant hospital” systems don't save money but instead can charge multiple times more than regional competitors is now established from settled court cases.

Table Graphic Jump Location
Table 2 Dominating Critical Care to Dominate Its Revenue Stream

CPT = current procedural terminology; DRG = diagnosed related group; RVU = relative value units. See Table 1 legend for expansion of other abbreviations.

Figure 1
Figure Jump LinkFigure 1 One dominant institution critical care department collects 23.5% of clinical revenues from its hospitalist business in outlying hospitals. Pulmonary-critical care medicine practitioners in those hospitals now have to travel to further outlying hospitals and long-term acute care hospitals to replace revenue for clinical service siphoned off by the mother institution’s hospitalist business. The hospitalists “have the best [shortest] length of stay metrics” and “will be leaders in all aspects of hospital operations including infection control, workflow, patient satisfaction, and resource management.” (https://www.ccm.pitt.edu/clinical; and https://www.ccm.pitt.edu/hospitalist-division; accessed May 23. 2015)Grahic Jump Location

A small-hospital intensivist practice that includes pulmonary-critical care and other physicians may be part-time and less lucrative than at a dominant institution. But physicians put up with this situation because of the psychic bonus of regularly being the physician part of the team crucial to the patient’s survival. Local hospitals already require multipurpose use of staff and facilities and triage constrained ICU beds, which can become ward beds with reduced staffing when the latter aren't available. Fragile noncritically ill patients can be monitored in an ICU for a time rather than a ward where night nurses are stretched thin. Some patients require such intensive care but not critical care; this is neither waste nor abuse of ICU beds.

For smaller hospitals in the sights of dominant institutions, the issue of “enough intensivists” boils down to this: Where will the prized critical care revenue go? In the traditional local hands-on model, there are pulmonary-critical care and other physicians who can do the work, staff the ICU themselves and with moonlighters as needed, and fill their non-ICU hours with pulmonary, sleep, and some internal medicine consults in the hospital and with office practice. The revenue and practitioners stay at the local hospital, where those practitioners pursuing excellence can build quality infrastructure. They don't need to churn ICU business and don't “burn out” in critical care because they swap the work with other specialists who can also be part-time competent intensivists. With a longitudinal commitment to their hospital community, their goal is success for individual patients rather than just an out-of-ICU disposition and/or getting through the shift.

Adequately funding the foundation of a critical care service could be by mandate, with Joint Commission rule changes requiring every hospital to have at least one board-certified geographic locally-focused and named individual intensivist to organize a service with appropriate depth and excellent care protocols. Like having a supervisory laboratory pathologist, this would be a cost of doing business. With sick patients coming in the ED or becoming sicker after admission, each hospital similarly requires an intensivist. Geographically permanent intensivists add infrastructural committee support working with nurses, pharmacists, respiratory therapists, and other physicians in an ongoing way with protocolized approaches where consensus is often reached, not because of universal agreement but due to trust developed over time regarding one another’s commitment to doing what is best and fixing errors that emerge. Full-time geographic intensivists can use consistent approaches to help train their backup doctors, since research has now repeatedly demonstrated that solid work during daylight hours with night coverage appears to serve patients at least as well as 24-h intensivist attendings.,,

Smaller hospitals would not do transplants or develop extracorporeal membrane oxygenation services and the like; dominant institutions to handle these complex patients are essential. But if local institutions kept sufficient critical care services for their communities and the medical and surgical services that attract and produce such patients, central dominant institutions would have to face the reality of no further growth in some instances. Indeed, some would shrink.

During a crisis in government funding for science in the 1980s, preeminent Berkeley biochemist and editor-in-chief of the journal Science, Daniel E. Koshland, Jr, analyzed the rationale through which Big Science—supercollider projects and the like—was regarded as an infinite-sum game with add-ons, crowding out Little Science, which was treated as a zero-sum game. He described instead how Big Science and Little Science (the latter from which most useful discoveries flow) are both necessary, but how Big Science projects should be vetted and decided upon as Little Science projects are. By analogy, Big Critical Care should not consume the patients and revenue of Little Critical Care or uncritically push the latter’s practitioners into uncertain geographies. Instead, the scientific and medical claims of Big Critical Care advocates’ projects, including restricting slots for training, should be subjected to careful peer review, including some accomplished peers from outside both the immediate discipline and the academic society advocates, in order to avoid a predetermined outcome by selection of lions from some disciplines pitted against the lambs from others.,,

At present, not all qualified applicants are granted intensivist training positions. If intensivist training slots are to be further restricted, who will decide who fills them? Will some be unpaid (for wealthier trainees), or sponsored through complex business transactions that focus more on the sponsor and less on the applicant’s merits? What will happen to the primarily altruistic practice of training foreign graduates from less developed countries?

Paraphrasing Dr Koshland, what is important is to think big about Little Critical Care: how to grow excellent ICUs everywhere, to get expert flexible practitioners working outside the dominant institutions contributing to hands-on-patient care and participation in prospective clinical research networks, to make and refine the types of discoveries that will save and improve lives. Big Critical Care can contribute enormously to such a bright future if it would not put its own interests and revenue siphon at the center of every solution.

Should America have qualified intensivists with backup spread across the United States to serve community needs, or qualified intensivists restricted to central loci running the region’s critical care, but with stripped-down ICUs in the provinces? I want to see quality medical care, including critical care, get better and stronger every place, including every corner of my own country. Academic dominant institutions should follow the lead of the many that have made a mission of disseminating their own trainees and supporting enhancement of quality intensive care and other subspecialty care in their far-flung networks and beyond, rather than stripping expertise from outside their own centers. America’s short-term and long-term interests require that academic intensivists focus on high-priority genuine academic pursuits: (1) Excellent training and role-modeling by committed intensivists—professors who don’t rotate off service after merely 1 or 2 weeks, or even less; (2) excellent subspecialty clinical services not routinely found in the community; and (3) discovery research that physically touches patients, not merely computers filled with propensity score retrospective matching software. For some department leaders, this might feel like cold water thrown on expansion plans. Self-examination is no easier today than it was when Scotland’s wondrous Robert Burns wrote in “To a Louse”: “O [would] some Pow’r the giftie gie us, To see oursels as others see us! It [would from manie] a blunder free us.”

Kahn J. .Rubenfeld G. . The myth of the workforce crisis: why the US does not need more intensivist physicians. Am J Respir Crit Care Med. 2015;191:128-134 [PubMed]journal. [CrossRef] [PubMed]
 
Anderson G.F. .Han K.C. .Miller R.H. .Johns M.E. . A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists. Health Serv Res. 1997;32:139-153 [PubMed]journal. [PubMed]
 
Longwell C.B. .Steele J.T. Jr.. The rise and fall of certificate of need in Pennsylvania. Widener Law Journal. 2011;21:185-212 [PubMed]journal
 
Detsky A.S. .Berwick D.M. . Teaching physicians to care amid chaos. JAMA. 2013;309:987-988 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. . Virtual visits—confronting the challenges of telemedicine. N Engl J Med. 2015;372:1684-1685 [PubMed]journal. [CrossRef] [PubMed]
 
Medicare incorrectly paid hospitals for beneficiaries who had not received 96 or more hours of mechanical ventilation.https://oig.hhs.gov/oas/reports/region9/91202066.pdf. Accessed May 24, 2015.
 
Herzlinger R.E. .Richman B.D. .Schulman K.A. . Market-based solutions to antitrust threats—the rejection of the Partners settlement. N Engl J Med. 2015;372:1287-1289 [PubMed]journal. [CrossRef] [PubMed]
 
Kerlin M.P. .Harhay M.O. .Kahn J.M. .Halpern S.D. . Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147:951-958 [PubMed]journal. [CrossRef] [PubMed]
 
Kerlin M.P. .Small D.S. .Cooney E. .et al A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368:2201-2209 [PubMed]journal. [CrossRef] [PubMed]
 
Garland A. .Roberts D. .Graff L. . Twenty-four hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185:738-743 [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. To lift the lamp beside the research door. Science. 1986;233:609- [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. Setting priorities in science. Science. 1988;240:965- [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. The funding crisis. Science. 1990;248:1593- [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 One dominant institution critical care department collects 23.5% of clinical revenues from its hospitalist business in outlying hospitals. Pulmonary-critical care medicine practitioners in those hospitals now have to travel to further outlying hospitals and long-term acute care hospitals to replace revenue for clinical service siphoned off by the mother institution’s hospitalist business. The hospitalists “have the best [shortest] length of stay metrics” and “will be leaders in all aspects of hospital operations including infection control, workflow, patient satisfaction, and resource management.” (https://www.ccm.pitt.edu/clinical; and https://www.ccm.pitt.edu/hospitalist-division; accessed May 23. 2015)Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Flaws and Harms of Proposed Dominant Institution Paradigm for Critical Care

NP = nurse practitioner; PA = physician assistant.

Table Graphic Jump Location
Table 2 Dominating Critical Care to Dominate Its Revenue Stream

CPT = current procedural terminology; DRG = diagnosed related group; RVU = relative value units. See Table 1 legend for expansion of other abbreviations.

References

Kahn J. .Rubenfeld G. . The myth of the workforce crisis: why the US does not need more intensivist physicians. Am J Respir Crit Care Med. 2015;191:128-134 [PubMed]journal. [CrossRef] [PubMed]
 
Anderson G.F. .Han K.C. .Miller R.H. .Johns M.E. . A comparison of three methods for estimating the requirements for medical specialists: the case of otolaryngologists. Health Serv Res. 1997;32:139-153 [PubMed]journal. [PubMed]
 
Longwell C.B. .Steele J.T. Jr.. The rise and fall of certificate of need in Pennsylvania. Widener Law Journal. 2011;21:185-212 [PubMed]journal
 
Detsky A.S. .Berwick D.M. . Teaching physicians to care amid chaos. JAMA. 2013;309:987-988 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. . Virtual visits—confronting the challenges of telemedicine. N Engl J Med. 2015;372:1684-1685 [PubMed]journal. [CrossRef] [PubMed]
 
Medicare incorrectly paid hospitals for beneficiaries who had not received 96 or more hours of mechanical ventilation.https://oig.hhs.gov/oas/reports/region9/91202066.pdf. Accessed May 24, 2015.
 
Herzlinger R.E. .Richman B.D. .Schulman K.A. . Market-based solutions to antitrust threats—the rejection of the Partners settlement. N Engl J Med. 2015;372:1287-1289 [PubMed]journal. [CrossRef] [PubMed]
 
Kerlin M.P. .Harhay M.O. .Kahn J.M. .Halpern S.D. . Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147:951-958 [PubMed]journal. [CrossRef] [PubMed]
 
Kerlin M.P. .Small D.S. .Cooney E. .et al A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368:2201-2209 [PubMed]journal. [CrossRef] [PubMed]
 
Garland A. .Roberts D. .Graff L. . Twenty-four hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185:738-743 [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. To lift the lamp beside the research door. Science. 1986;233:609- [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. Setting priorities in science. Science. 1988;240:965- [PubMed]journal. [CrossRef] [PubMed]
 
Koshland D.E. Jr.. The funding crisis. Science. 1990;248:1593- [PubMed]journal. [CrossRef] [PubMed]
 
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