Critical Care Medicine Needs YOU

Anesthesiologists played a key role in establishing critical care as an independent multidisciplinary subspecialty. Over the years, however, the role of anesthesiologists in critical care has diminished significantly. Recent developments in the health care marketplace provide an avenue and the imperative for our return to the intensive care unit (ICU) in force.

The practice of critical care or intensive care medicine will play an increasingly large role in the delivery of health care to an aging population in the United States. With the ability to perform high-risk procedures on higher-risk patients, more and more individuals require an enhanced level of care. We have met this challenge in the operating room (O.R.), where once experimental operations are now routinely performed on patients previously considered "too sick for surgery." Our expertise is now needed in ICUs.

A study examining workforce issues in critical care in the United States — the Committee on Manpower for Pulmonary and Critical Care Societies, or COMPACCS, study — clearly documents that there will be a dearth of trained ICU physicians in the near future. In several studies, Peter J. Pronovost, M.D., Ph.D., and coworkers have alerted consumers that the presence of a trained intensivist improves outcome. This understanding is typified by the recommendations of the Leapfrog Group, a consortium advising several high-profile consumers of health care services. The Leapfrog Group recommends that a board-certified intensivist be available to provide care in ICUs on a full-time basis. Thus the demand for physicians trained as intensivists is growing and undoubtedly will continue to escalate.

The American Society of Critical Care Anesthesiologists (ASCCA) is committed to helping us meet this challenge. ASCCA’s mission is to preserve and expand the pivotal role of critical care medicine, as practiced by intensivists in intensive care units, within the scope of practice of anesthesiology. This will be accomplished through education, advocacy and community. Four guiding principles arise from this mission:

1. Intensivists are an integral component of the modern health care system because they improve the quality and cost-effectiveness of patient care.

2. Intensive care medicine is an essential subspecialty of anesthesiology practice because it enhances the overall quality of perioperative care.

3. Anesthesiologists with special training and experience in intensive care medicine improve the quality of postoperative care by advancing our understanding of critical illness; they also contribute to major improvements in intraoperative management and outcomes. Continued participation in critical care medicine is essential to the future of the specialty and to continued improvements in perioperative care.

4. The present number of anesthesiology intensivists is insufficient to meet current and future needs of patients and practices; thus the number of trainees needs to be increased.

To help achieve this mission and implement these principles, ASCCA proposes that:

1. There must be an increase in the number of anesthesiology intensivists. This requires that we alter the educational system to provide focused education to medical students and residents and increase the number of anesthesiologists seeking advanced training in intensive care.

2. There must be an enhanced understanding of the value intensivists bring to patient care. We need to educate accreditors, regulators, purchasers, payers, hospital administrators and the consumer on the value of anesthesiology intensivists, participate in local, regional and national forums and encourage the production and dissemination of outcomes data.

3. The anesthesiology community in particular and the health care community in general needs to recognize the benefits that anesthesiology intensivists bring to clinical practice.

This mission will require input from all of us, intensivists and nonintensivists alike. ASCCA has restructured its committee system to address these objectives. The American Board of Anesthesiology (ABA) has shown its commitment via proposals to modify the continuum of anesthesiology education and increase the exposure of resident anesthesiologists to critical care medicine. ASA has altered its Annual Meeting, entertained proposals to enhance the footprint of intensivists within the organization and set up a forum where dialogue with subspecialty organizations is fostered. Both our journals (Anesthesiology and Anesthesia & Analgesia) have made clear their desire to publish high-level critical care research. The Foundation for Anesthesia Education and Research (FAER) has recently funded the first joint FAER/ASCCA Critical Care Research Grant. ASCCA is sponsoring a $75,000/year grant for a young investigator in critical care.

What remains is for all of us to approach these issues as individuals and as a group, making the local, regional and national agenda our own. Make intensive care medicine part of your group’s practice. Negotiate contracts that contain reimbursement for ICU coverage (individuals within ASCCA can assist you). Educate your hospital administrators, your professional colleagues, your legislators and your patients. Anesthesiology is the practice of medicine, and by extension, the practice of intensive care medicine. Help to nurture this viable, growing specialty!

Clifford S. Deutschman, M.D., is Professor of Anesthesia and Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.