A Critical Care State of Mind

2015 - 2 April – Clinical Controversies
Ashish K. Khanna, MD, FCCP; Lewis J. Kaplan, MD, FCCM
In this article, two experts discuss the characteristics that define intensivists.


The Society of Critical Care Medicine’s (SCCM) In-Training Section is dedicated to assisting and guiding trainees as they progress through training
into independent practice. It also aims to foster career development following this transition. To further this mission, members contribute articles
addressing emerging issues in critical care training and career development; these submissions are authored by in-training professionals under the guidance of a mentor. For additional information about the In-Training Section or this project, please contact Section Chair Utpal Bhalala, MD, Chair-elect Ashish Khanna, MD, FCCP, or Member-at-Large Erik Vakil, MD.

Critical care is practiced in a host of locations and fashions, hewing closely to the guiding principle that “critical care is a concept, not a location.”(1) Resonating well with the mission and vision of the Society of Critical Care Medicine (SCCM), those words also frame a question: Who is an intensivist? One may envision many different answers, depending on one’s specialty, location and resources (including personnel).
 
In the United States, Certificates of Added Qualifications in critical care medicine are awarded by the American Board of Anesthesiology, the American Board of Internal Medicine, the American Board of Pediatrics, and the American Board of Surgery. For emergency medicine physicians interested in subspecialty board certification in critical care medicine, various formalized pathways exist in the United States; essentially, they require a two-year fellowship followed by formal examination.(2) While the pathways to U.S. certification are clear, the practice of critical care medicine embraces more than board certification.

This practice may be characterized by pooling together a team of dedicated experts with a range of specializations to comprehensively care for the critically ill and injured. In essence, it is about embracing a systematic and team-based approach to analyze and influence the restoration and maintenance of homeostasis. Within the prototypical medical school-driven institution, critical care medicine is often sequestered by parent specialty certification. However, many institutions have embraced multispecialty practice by rotating the “intensivist of the week” from one specialty to another.(3) For instance, one week the intensivist might come from internal medicine, the next week from anesthesia; many rotation variations exist and more can be imagined. Within community institutions, many intensive care units (ICUs) are mixed medical and surgical, with pulmonary critical care medicine specialists and anesthesia critical care medicine specialists predominating. These institutions are not typically ordered around a parent specialty; instead, the organizational structure is likely dictated by human capital availability. Dynamics could change, however, as physicians continue to shift from private practice to salaried jobs with hospitals.(4)
 
Setting the variations in models aside, who serves as the intensivist in facilities where no one on staff is specifically trained and certified in critical care medicine?  Multiple studies support the salutary impact of the intensivist model and of employing full-time intensivists.(5,6)  Physical presence, availability to address specific problems and, in particular, the construction and guidance of a consistent and evidence-supported, team-based approach to patient care underpin many of the benefits of the intensivist model. That said, it is increasingly clear that a variety of individuals can act as an intensivist and guide a team in the ICU. Such individuals may be hospitalists, primary care physicians or internal medicine physicians, or they could also be advanced practice providers (advanced practice nurses or physician assistants) or doctors of pharmacy who are geographically fixed in the ICU as a dedicated hospital asset. While the latter are not traditionally considered intensivists, they may help to address the existing shortage in critical care medicine providers across the United States.

More than a decade ago, the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) reported that fewer than 6,000 board-certified (in critical care medicine) intensivists were in active practice in the United States.(7) Around this same time, The Leapfrog Group reported that dedicated intensivist staffing was employed in only 10% to 20% of U.S. ICUs and that units without dedicated intensivists had little hope of hiring them from the limited pool available.(8) An increase in the shortfall of intensivists over time also was predicted. There are some indications, however, that the tide has begun to shift. Perhaps as a result of the highlighted shortfall, a career as an intensivist is increasingly popular among recent U.S. medical school graduates.(9)

Critical care medicine engages knowledge about normal and abnormal physiology and packages it in a rather selfless way to help those who are often at the crossroads of life and death. Establishing rapport and trust is a key aspect of rendering high quality care.  Intensivists help not only the patient but also the family, a key characteristic of the specialty. The recent focus on palliative care and the quality of both life and death may also influence the rapid inclusion of palliative care specialists into the ICU team.(10) In an earlier issue of Critical Connections, palliative care specialists were also identified as playing an important role in conflict management.(11) As a result, these providers may also serve as team leaders when a traditional board-certified intensivist is not on hand.

To quote an ICU mentor of mine, a good intensivist must have:

• The keen observation of a pediatrician (ventilated ICU patients cannot talk)
• The patience of an obstetrician (watchful waiting is a part of beneficial therapy)
• The thoughtfulness of a physician (multiple complex problems need sorting)
• The rapid reflexes of an anesthesiologist (quick thinking and action as needed)
• The aggressiveness of a surgeon (definitive invasive intervention when needed)
• The communication skills of a psychiatrist (families and friends need counseling)

Synthesizing all of these skills is the intensivist, who crosses specialty boundaries and knowledge lines and provides dedicated team direction, while offering emotional support, empathy and compassion throughout critical illness and injury management.  It is clear that individuals with various backgrounds may embody such attributes. While the future holds the promise of expanding the number of intensivists, our current deficit compels us to explore and embrace all who may serve patients by driving team-based care in the ICU. Truly, critical care is more than a medical or surgical specialty—it is a state of mind.

References:

1.Safar P, Grenvik A. Critical care medicine. Organizing and staffing intensive care units. Chest. 1971 May;59(5):535-547.
2. American College of Emergency Physicians.  ACEP critical care medicine. https://www.acep.org/_Critical-Care-Section-MicroSite/Critical-Care-Section---FAQs/. Accessed April 29, 2015.
3. Tisherman SA, Kaplan L, Gracias VH, et al; Surgery Section, Society of Critical Care Medicine. Providing care for critically ill surgical patients: challenges and recommendations. JAMA Surg. 2013 Jul;148(7):669-674.
4. Rosenthal E. Apprehensive, many doctors shift to jobs with salaries. The New York Times. 2014 Feb. Available at: http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html. Accessed April 29,2015.
5. Wilcox ME, Chong CA, Niven DJ, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013 Oct;41(10):2253-2274.
6. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002 Nov 6;288(17):2151-2162.
7.Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet  the requirements of an aging population? JAMA. 2000 Dec 6;284(21):2762-2770.
8.  Pronovost PJ, Needham DM, Waters H, et al. Intensive care unit physician staffing: financial modeling of the Leapfrog standard. Crit Care Med. 2004 Jun;32(6):1247-1253.
9.‘Critical Care’ Is a Rising Med School Specialty. US News & World Report. Available at: www.usnews.com/education/articles.
10. Toevs CC. Palliative medicine in the surgical intensive care unit and trauma.
Anesthesiol Clin. 2012 Mar;30(1):29-35.
11. Kayser J. Ethics, Communication and the ICU: charting a course for resolving conflict. Critical Connections. August 4, 2014. Available at: http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Ethics,-Communication-and-the-ICU-Charting-a-Course-for-Resolving-Conflict.aspx.