ASA September 2003 Newsletter

The health care industry’s interest in improving quality of care without hindering efficiency applies to all medical specialties, and the subspecialty of critical care medicine (CCM) is not exempt. Continued focus on patient safety, length of stay, expenditures and outcomes is at issue not only in the medical media but the lay media as well. This is specifically apparent in the Leapfrog Group’s recent initiative that requires a dedicated intensivist for intensive care unit (ICU) staffing models.¹ The impetus for an intensivist model has been spurred by evidence that such a model improves patients’ outcomes, decreases their length of stay and reduces costs.^2-5

Many ICUs in the United States are organized as an “open” model in which input from an intensivist is variable, if it is even given at all. The “closed” model imposes stricter controls on patient care, triage and admittance to the ICU mandating the patient’s care transferred to the intensivist or critical care team. Recent data suggest decreased lengths of stay, improved outcomes, efficiency and resource utilization when ICU structure is changed from an open to a closed setting.^{6, 7}

According to the American College of Critical Care Medicine (ACCCM), the definition of an intensivist encompasses the physician’s credentials, focus of care and unencumbered immediate physical availability to the ICU. In addition the role requires expertise in managing multisystem insults while performing appropriate procedures/maneuvers and capacity for education and administrative responsibilities.⁸

Anesthesiologists, as hospital-based physicians, should make a good source of intensivists. Their training emphasizes recognition, diagnosis and manipulation of physiologic perturbations as they occur in real time in the operating suite, with patient acuity and equipment very similar to that of the ICU. In addition, because patients with virtually any disease process may need surgical intervention, the anesthesiologist’s training requires experience with and understanding of a wide spectrum of acute and chronic illnesses.

Currently there are an estimated 10,244 intensivists in the United States, and of these, approximately 2,600 to 4,600 are actively practicing in an ICU with about 23 percent practicing CCM full-time.^9,10 Current estimates indicate a need for 33,000 intensivists to implement staffing models that approximate the Leapfrog Group’s requirements. For 2002-03, there are a total of 333 CCM programs in the United States with 1,569 trainees enrolled. [Figure 1].

Figure 1. Critical Care Training Programs by Specialty and Positions Filled

Program by Specialty	# of ACGME Accredited Programs	# of Positions Filled
Anesthesiology	51	66
Internal Medicine	32	143
Pediatrics	57	260
Pulmonary	121	1010
Surgery	72	90
Total:	333	1,569

Based on current trainee information, the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) estimates intensivist supply will meet demand until the year 2007, following which a shortage upwards of 20 percent will occur by 2020 and 35 percent by 2030. Approximately 80 percent of the critical care workforce is provided by physicians with a pulmonary medicine-based specialty. Of this group, only 23 percent of their clinical time is spent in the ICU while almost 70 percent is spent providing non-ICU pulmonary care.⁹ Therefore, a probable underestimate of supply exists when one considers the percentage of graduates each year who enter the job market and practice CCM. Compounding the problem is that by 2030, Medicare enrollment will increase by more than 50 percent, thereby placing a larger burden on the supply of intensivists.

Critical care training is provided in a multidisciplinary fashion, and anesthesiology is represented least well, supplying only 4 percent of the total trainee enrollment. According to the American Board of Anesthesiology (ABA), there are 1,030 board-certified critical care anesthesiologists in the United States, representing a mere 10 percent of the estimated U.S. intensivists. Presently anesthesiologists make up only 12 percent of the membership of the Society of Critical Care Medicine. Concerned about this disproportion in the face of excellent employment opportunities for the foreseeable future, we surveyed the current second- and third-year residents in all Accreditation Council for Graduate Medical Education (ACGME)-accredited U.S. anesthesiology programs. The purpose of this study was to gain insight into the perception(s) of CCM by anesthesiologists-in-training.

We created a 15-question survey that was distributed via e-mail to all program directors of ACGME-accredited U.S. anesthesiology training programs with instructions to dispense to all second- and third-year anesthesiology residents. We chose second- and third-year residents as they were more likely to have formulated an opinion about CCM based on their significant exposure to it. The responses to the questionnaire were collected over a three-month period from July to September 2002. All responses were obtained anonymously.

Results
There are a total of 1,326 CA-2 and CA-3 residents in ACGME-accredited anesthesiology training programs in the United States. From these we received 238 responses for a response rate of 18 percent, assuming all programs did in fact distribute questionnaires to all the residents. The responses to each question can be found in more detail on the ASA Web site. Forty-five percent of the respondents had completed three or more months in CCM of which the majority were spent in a surgical/trauma unit staffed by anesthesiologists 40 percent of the time.

To summarize our results, we found that almost 25 percent of residents chose anesthesiology for the procedure-related practice involved. Many also considered training in surgery, emergency medicine or internal medicine. Only 26 percent stated they will pursue an academic career. Nearly all respondents considered themselves perioperative physicians. Fifteen percent considered CCM as a subspecialty, and almost all felt that their experience would impact their practice positively despite taking call two to three times per week. More than 80 percent stated that their CCM staff rotates in the operating room and are treated with equal if not more respect than their non-CCM colleagues. Nearly all believed a dedicated intensivist is beneficial.

Perhaps the most disturbing response is that 25 percent felt there is little market demand for CCM outside the academic setting, and 47 percent did not know.

Discussion
Our survey is limited by a small response rate; however, it does afford a revealing view of a misguided perception held by most of the respondents.

A common misconception of our respondents was that the demand and potential for intensivists is limited to academic practice, which we believe will not be true if the Leapfrog Group’s initiatives are instituted. Anesthesiology residents in training are unaware of this and feel that there is little demand. This creates an enormous challenge for anesthesiology CCM fellowship training programs to recruit candidates as they must contend with this existing mindset and a perception that needs to be changed. A focus on changing this perception offers great potential in recruiting future intensivists into the subspecialty.

Thus the practice of anesthesiology lies at a crossroads with the number of applicants entering training programs showing an increasing trend and a proposed demand for a subspecialty it helped to create. If in fact the shortage experienced in the late 1990s is recovering, how do we capitalize on our new recruits?

Perhaps the most pressing question that needs to be addressed is why more of our residents do not choose to pursue fellowships in CCM. Is it because of a perception of poor market demand for CCM and an exceptional market for operating room practice? Is it the quality of the lifestyle that the private practice anesthesiologist is believed to lead? Perhaps their ICU experience was malignant?

An interesting contrast can be seen in comparing anesthesiology with pulmonary medicine, which is currently very well-represented by trainees in critical care programs. Pulmonary medicine training includes critical care certification, where anesthesiology requires formal fellowship training beyond the primary specialty program. Perhaps ABA might offer an optional certification for anesthesiology and critical care medicine by modification of training time and requirements of time spent in critical care environments rather than a formal fellowship.

Currently two months spent in CCM rotations is all that is necessary to fulfill requirements of ACGME-accredited anesthesiology training programs. Increasing the minimum time requirement in CCM rotations at the very least helps to promote the image and role of the perioperative physician, not to mention confidence in managing high-acuity patients. Another possibility to aid in recruitment of trainees is creating a “CCM track” for those residents interested in pursuing a career in critical care anesthesiology. More ICU time would be spent during the preliminary and clinical anesthesia training years, and if proficiency is validated, less postgraduate time would be necessary to fulfill board requirements. This may be an attractive alternative for those who consider pursuing subspecialty training but are reluctant when they can enter the job market and begin repayment of educational debt.

The concept of the anesthesiologist as a practitioner of perioperative medicine outside the operating room needs to be solidified and used to dissuade the common perception that anesthesiologists are physicians who provide a vital yet limited role in a patient’s care. We need to not only change the mindset of the community but also help to promote and garner the image in our residents’ minds, encouraging them to think outside “the box” of the operating room.

ABA and ASA challenge the specialty to develop the role of anesthesiologists as perioperative physicians. The November 2002 ASA NEWSLETTER devoted an entire issue to the perioperative physician, and our survey respondents clearly believe that anesthesiologists are perioperative physicians. No other subspecialty can match our familiarity with airway management, physiologic and pharmacologic manipulation of the cardiopulmonary circulation, fluid management and resuscitation, mechanical ventilation and invasive monitoring techniques. To hone the skills obtained in CCM residency is only a natural progression from the operative suite to the ICU.

We should work toward staffing the very ICUs we helped to create with our fresh new recruits as well as forge new areas such as the hospitalist arena. It is our responsibility to reverse the misconception of a bleak market demand for critical care anesthesiologists. Rather than redefine ourselves, we need to regain our reputation now as perioperative physicians instead of achieving recognition “posthumously.”

Figure 2: Results by Question

References:

1. Milstein A, Galvin RS, et al. Improving the safety of health care: The Leapfrog Initiative. Effective Clinical Practice. Nov/Dec 2000; American College of Physicians-American Society of Internal Medicine. <www.acponline.org/journals/ecp/novdec00/milstein.htm>.

2. Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Effective Clinical Practice. Nov/Dec 2000; American College of Physicians-American Society of Internal Medicine. <www.acponline.org/journals/ecp/novdec00/young.htm>.

3. Hanson CW, Deutschman CS, et al. Effects of an organized critical care service on outcomes and resource utilization. A cohort study. Crit Care Med. 1999; 27:270-274.

4. Pronovost PJ, Jenckes MW, et al. Organizational characteristics of intensive care units related to outcomes of abdominal surgery. JAMA. 1999; 281:1310-1317.

5. Dimick JB, Pronovost PJ, et al. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost and complications after esophageal resection. Crit Care Med. 2001; 29:753-758.

6. Multz AS, Chalfin DB, et al. A “closed” medical intensive care unit (MICU) improves resource utilization when compared with an “open” MICU. Am J Respir Crit Care Med. 1998; 157:1468-1473.

7. Ghorra S, Reinert SE, et al. Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann Surg. 1999; 229:163-171.

8. Brilli RJ, Spevetz A, et al. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med. 2001; 29:2007-2019.

9. Angus DC, Kelley MA, et al. 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.

10. Hurford WE, Maccioli GA, et al. A new beginning for anesthesia critical care: Changes and challenges for the workforce. ASA Newsl. 2002; 66(8):12-14.

Robert M. Pousman, D.O., is Assistant Professor/Assistant Director of Critical Care Services, Vanderbilt University Department of Anesthesiology/ Division of Critical Care and Perioperative Medicine, Nashville, Tennessee.

C. Lee Parmley, M.D., J.D., is Associate Professor and Chair, Department of Critical Care, University of Texas M.D. Anderson Cancer Center and University of Texas-Houston ACCM Program Director, Houston, Texas.

return to top