The Critical Care Physician Workforce: An Update from SCCM
The workforce issues facing critical care are well known within healthcare circles as concerns about shortages of nurses, pharmacists, respiratory therapists and critical care physicians become more pressing throughout the world. The issue has seen increased attention within the United States as President Barack Obama takes an aggressive approach to healthcare reform and as the aging U.S. population exacerbates the crisis. In this issue of Critical Connections, the Society of Critical Care Medicine (SCCM) revisits the critical care physician workforce shortage by reviewing previous and current efforts to identify and solve the problem, by updating its analysis of fellowship positions, and by assessing outside factors affecting the shortage.
Physician Supply and Demand
In 2006, the Association of American Medical Colleges (AAMC) recommended a 30% increase in U.S. medical school enrollment and an expansion of graduate medical education positions to accelerate and accommodate physician supply. A year earlier, the Council on Graduate Medical Education (COGME), in its report “Physician Workforce Policy Guidelines for the United States, 2000-2020,”(1) called for a 15% increase in the total enrollment in U.S. medical schools over 10 years.
While these increases in medical school enrollment play some part in relieving shortages, the AAMC in November 2008 claimed that – given any set of plausible assumptions – the supply of physicians in the United States likely will continue to decline while demand for physician services grows, fueled by a growing and aging population that is living longer. Figure 1 reflects the baseline supply and demand for full-time physicians through 2025; assuming that current trends of supply, use and demand continue unchecked, a shortage of 124,000 physicians is projected.(2)
Simply training more physicians will be insufficient to tackle the shortfall in the physician workforce. The approach must be comprehensive with goals that improve effectiveness and quality of care, reengineer and reconfigure delivery models, change financing methodologies, and make better use of physician supply.
The Critical Care Focus
The physician shortage is even sharper for critical care medicine. Three years after the release of the Health Resources and Services Agency (HRSA) report,(3) two questions still bear consideration: Is there currently a sufficient supply of critical care physicians, and will the supply be sufficient over the next decade to meet the demand for critical care services?
The proportion of patients receiving care under the direction of an intensivist has risen significantly and is likely to continue; upper-limit projections indicate intensivist physicians will care for two-thirds of all intensive care unit (ICU) patients while lower-limit calculations put the number at one-third.(3) Notwithstanding these limits, the HRSA analysis supported the conclusion that demand will continue to outpace the available supply through the year 2020. This is still the case in 2009. Although the supply of critical care physicians is expected to remain steady throughout the next decade (as new employees replace those retiring), it will not be enough to fulfill increasing demand.
Are We Training Enough Future Physicians?
The length of time involved in the education, training and “production” of qualified and experienced intensivist physicians is great. A critical care physician may take up to eight years of postgraduate training (residency and critical care fellowship) and four more years of medical or osteopathic school. Career decisions must be made at least a decade in advance. For educators and policymakers, as well as potential physicians, the actions to solve the 2020 workforce shortage must be taken today.
Just as SCCM noted in its June 2006 Critical Connections article on the critical care workforce,(4) current data from the Accreditation Council for Graduate Medical Education (ACGME) again show a slight but steady increase in all critical care physician fellowship programs (see Figure 2). The number of overall filled fellowship positions increased 4.4% (82 positions) from 2006/07 to 2007/08, with an overall increase of 18.5% (306 positions) from 2003/04 to 2007/08. Critical care subspecialties show more trainees now than in the past several years, with combined pulmonary/critical care medicine continuing as the most popular pathway.
• Trainees in anesthesia/critical care subspecialty programs increased 30.2% (16 positions) from 2006/07 to 2007/08. However, it is important to note that the previous academic year (2005/06 to 2006/07), a 7.7% (7 positions) decrease was noted. Despite this fluxuation, an overall increase of 19.9% (10 positions) has been seen from 2003/04 and 2007/08. In SCCM’s last report, a 22.2% overall increase was seen from 2001/02 to 2005/06.
• Trainees in critical care medicine (internal medicine) increased 5.9% (9 positions) from 2006/07 to 2007/08, with an overall increase of 3.2% (5 positions) between 2003/04 and 2007/08. In SCCM’s last report, an overall 13.5% increase was seen from 2001/02 to 2005/06.
• Trainees in combined pulmonary/critical care medicine increased 3.2% (39 positions) from 2006/07 to 2007/08, with an overall increase of 17.4% (185 positions) between 2003/04 to 2007/08. In SCCM’s last report, an overall 10.7% increase was seen from 2001/02 to 2005/06.
• Trainees in pediatric critical care increased 2.7% (9 positions) from 2006/07 to 2007/08, with an overall increase of 28.4% (77 positions) between 2003/04 and 2007/08. In SCCM’s last report, a 17.8% overall increase was seen from 2001/02 to 2005/06.
• Trainees in surgical critical care increased 6.9% (9 positions) from 2006/07 to 2007/08, with an overall increase of 26.1% (29 positions) between 2003/04 and 2007/08. In SCCM’s last report, a 38.7% overall increase was seen from 2001/02 to 2005/06.
Overall, critical care fellowship programs have been able to fill about 85% of the approved fellowship positions from 2005/06 to 2007/08 (see Figure 3). The combined pulmonary/ critical care medicine fellowships have been filling at roughly 90% of capacity, while anesthesiology fellowships are at just over 50% of capacity. Pediatric fellowships stand at about 83% of capacity, while surgical fellowships were at 80% and 70% capacity between 2005/06 and 2007/08, respectively. Anesthesia and surgical programs are stable but continue to fill at slower rates than the other three fellowship programs.
Exploring Indirect Solutions
As part of the Critical Care Workforce Partnership, SCCM has worked to increase the supply of critical care providers through efforts in cross-training, growing the capacity of medical and nursing schools to train critical care providers,and expanding federally funded graduate medical education slots for critical care. However, simply increasing the number of critical care fellowship slots will not be enough. Lifestyle issues and the intensity of the training are obstacles to fellowship completion as well as to the pursuit of critical care practice generally.
Resident work hour restrictions. In December 2008, the Institute of Medicine (IOM) released a report calling for revisions to medical residents' workloads to decrease the chances of fatigue-related medical errors and to enhance the learning environment.(6) In a joint letter, SCCM, the American Thoracic Association (ATS), and the American College of Chest Physicians (ACCP), urged the ACGME not to implement these new IOM recommendations to apply further, more sweeping duty-hour restrictions without considering additional issues in the training of physicians and the delivery of care to patients, their families and the public. Most recently, a study published in The New England Journal of Medicine found that such changes could result in a potential $1.6 billion price tag, but could also aggravate the workforce shortage.(7) Researchers estimated that residency positions would need to grow by about 8% overall to meet staffing needs under the IOM recommendations. The broad implications and unintended consequences of work hour restrictions – including their potential to hinder formal training, jeopardize continuity of care and effect professionalism – considered individually may not be directly related to the current critical care workforce shortage. However, taken together, these restrictions may have an impact on the duration, intensity and attractiveness of critical care practice.
Legislation. A new version of the Patient-Focused Critical Care Enhancement Act was introduced to the U.S. House and Senate in March and May of 2009, respectively. The act seeks to optimize the delivery of critical care services by conducting research on optimal critical care delivery models and by providing support for research into therapies and treatments. The Society is monitoring the bill’s progress closely, as the legislation also would seek to improve care in the rural and underserved areas most affected by the workforce shortage and to invest in new technologies, such as telemedicine.
Staffing. Developing and inventing new staffing models also may also help alleviate demand for critical care physicians. Physician assistants and nurse practitioners trained in critical care could play a larger role in caring for intensive care patients. In line with this thinking, SCCM continues to encourage use of its Fundamental Critical Care Support (FCCS) program, with special attention to those in rural and underserved areas. FCCS works to educate non-intensivist physicians, nurses, physician assistants, and other providers about critical care and could have a key role in offsetting portions of the shortage. Growth in participation in FCCS has been dramatic, with 15% more individuals being training in the program in 2009 than the prior year, which also saw substantial growth.
In addition, hospitalist and emergency department physicians now are able to train in critical care medicine to supplement and extend the workforce when intensivists are not available. Critical care medicine requires fellowship training, but it is not currently a board-certified subspecialty in the United States; it is considered a “certificate of added qualification.” An American Board of Emergency Medicine (ABEM) certifying examination in critical care medicine does not exist, but one likely will be developed as demand grows. The European Society of Intensive Care Medicine (ESICM) offers an alternative route to certification.(8) After completing two years of critical care fellowship training, emergency medicine-trained physicians from the United States may sit for the European Diploma in Intensive Care Medicine examination. Acceptance of the European Diploma in Intensive Care Medicine for credentialing purposes is hospital-dependent.
Delivery of Critical Care Services. In addition to monitoring the telemedicine efforts outlined in the Patient-Focused Critical Care Enhancement Act, the Society is exploring other opportunities within this budding field. SCCM’s Tele-ICU Committee intends to post an extensive history of telemedicine. In addition, the “Quad Societies” – SCCM, ATS, ACCP, and The American Association of Critical-Care Nurses (ACCN) – recently submitted a grant proposal to the Agency for Healthcare Research and Quality (AHRQ) to fund a telemedicine workshop. The workshop would examine telemedicine’s role in relieving the workforce shortage as well as in improving the quality of care and patient safety. Gathering data and educating healthcare professionals is especially important considering the Centers for Medicare and Medicaid Services (CMS) again refused to add Current Procedural Terminology® (CPT) codes 99291 and 99292 to the list of approved telehealth services for 2010, citing insufficient data to suggest that the use of telemedicine was comparable to face-to-face encounters.
References:
1. Angus DC, et al. 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;284:2762-2770.
2. Critical Care Workforce Partnership position statement. The aging of the U.S. population and increased need for critical care services. AACN/ACCP/ATS/SCCM. http://www.sccm.org/sccm/Public+Health+and+Policy/AgingUSPopulation2001.pdf. Published November 2001. Accessed on July 21, 2009.
3. Kelley MA, et al. The critical care crisis in the United States: a report from the profession. Chest. 2004;125:1514-1517.
4. Health Resources and Services Administration. The critical care workforce: a study of the supply and demand for critical care physicians. Report to Congress. http://bhpr.hrsa.gov/healthworkforce/reports/criticalcare/default.htm. Published in 2006. Accessed on July 21, 2009.
5. Institute of Medicine. Report brief: future of emergency care in the United States health system. Washington, DC: National Academies Press; 2006.
6. Council on Graduate Medical Education. Sixteenth report: Physician workforce policy guidelines for the United States, 2000-2020. http://www.cogme.gov/16.pdf. Published January 2005. Accessed July 21, 2009.
7. Association of American Medical Colleges; Center for Workforce Studies. The complexities of physician supply and demand: projections through 2025. http://www.aamc.org/workforce/. Published November, 2008. Accessed on July 21, 2009.
8. Chandler E, et al. Are there more critical care physician trainees today? Critical Connections. 2006;5(3):1,16.
9. Institute of Medicine. Report brief: resident duty hours; enhancing sleep, supervision, and safety. Washington, DC: National Academies Press; 2008.
10. Nuckols TK, et al. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360:2202-2215.
11. Cawdery M, et al. Emergency medicine career paths less traveled: cruise ship medicine, Indian health, and critical care medicine. Ann Emerg Med. 2004; 44:79-83.
12. Accreditation Council for Graduate Medical Education. Number of accredited programs and filled positions by specialty by academic year. http://www.acgme.org/adspublic. Accessed on July 21, 2009.
