Conclusion
American critical care training programs have failed to produce enough intensivists to meet demand, and this mismatch between supply and demand will substantially worsen over upcoming decades. Hospitals and healthcare systems, faced with the mandate to provide care for their ICU populations, have already innovated to offset this shortage through the use of telemedicine and the extension of nonphysician providers into ICUs. As the gap between intensivist supply and demand widens, healthcare systems will be increasingly likely to pursue more radical solutions, up to and including independently training their own critical care workforces. We believe that there are better alternatives.
Hospitalists have rapidly proliferated to become the dominant provider of inpatient medical care in American hospitals and are already providing a substantial amount of critical care. As such, they remain a largely untapped and potentially significant source of new intensivists. The skills, competencies, and values embodied in hospital medicine are already highly congruent with those of critical care. By virtue of their numbers and penetrance into the vast majority of large American hospitals, hospitalists are well situated to make a substantial impact on the intensivist shortage. If only 5% of the projected hospitalist workforce were to receive the critical care training that we propose, 2500 new intensivists would enter the critical care workforce, substantially decreasing the impact of the national intensivist shortage.
Internal medicine hospitalists who obtain additional training as intensivists would also bring new capabilities and flexibility to hospitals seeking to implement intensivist programs. In smaller hospitals that cannot support freestanding intensivist programs, hospitalist-intensivists might divide their time between ICU and ward duties. In larger hospitals, these clinicians might function exclusively as intensivists alongside their traditionally trained peers. Whether they affiliate as hospitalists, intensivists, or something else entirely will largely depend upon the roles that they fulfill, the governance of their institutions, and the departments that most effectively meet their clinical and organizational needs.
Bringing qualified hospitalists into the critical care workforce through rigorous sanctioned and accredited 1-year training programs, will open a new intensivist training pipeline and potentially offer more critically ill patients the benefit of providers who are unequivocally qualified to care for them. Similarly, unification of critical care training and certification across disciplines will better focus efforts to expand the intensivist workforce, more efficiently leverage limited training resources, and facilitate standardization of critical care skills, policies, and procedures across the nation's ICUs. Although moving this agenda forward may be logistically challenging and politically daunting, we believe that the results will be worth the effort.