s is true for anesthesiology as a whole,¹ critical care medicine (CCM) is facing a huge workforce crisis.² The clinical volume of critically ill patients continues to rise in every major hospital in the country; the acuity of inpatients is at an all-time high. At the same time, the number of clinicians trained for and interested in providing critical care services is not keeping up with the demand. As a result, critical care represents one of many opportunities for our specialty should we decide to accept it.

Currently the vast majority of certified and practicing intensivists in the United States are board-certified in internal medicine, and the preponderance of those practitioners are certified in pulmonary and critical care medicine.³ This is a radical change from the birth of the subspecialty of CCM, which was led by such anesthesiology legends as Myron B. Laver, M.D., Henning Pontoppidan, M.D., Henrik H. Bendixen, M.D., and J. Hedley-White, M.D., to name a few. Although these anesthesiologists saw the anesthesiologist as the perioperative physician before anyone coined the term, the specialty has shifted its focus back to the operating room (O.R.) for a number of reasons. The O.R. orientation is not surprising, since the surgical volumes and complexity continue to climb, and the need for highly skilled anesthesia providers is significant.

The return of anesthesiologists’ emphasis back to the O.R. has a multitude of explanations that we will not address in this manuscript. The question for us to consider is whether the medical specialty of anesthesiology can and will continue to embrace critical care as a viable opportunity to endorse and aggressively pursue.

Despite a large body of literature demonstrating that the critical care physician adds value to the care of the complex intensive care unit (ICU) patient, many hospitals provide only cursory oversight of the critically ill patient, providing fragmented care by a combination of primary care providers or groups of specialists with little coordination. In addition although the “closed” (specialist-practitioner only) ICU model has been demonstrated to improve outcome ^4-14 and optimize resource utilization,¹⁵ the vast majority of community hospital ICUs have “open” (any practitioner) admission and management policies. The traditional “open” model reduces friction between the medical staff and the intensivist in most instances but does little to improve the quality of care. Despite the advantages of the “closed” model of care and the potential opportunities it offers to the critical care-trained anesthesiologist, until recently, it has not been widely adopted due to issues of resource allocation, control of patients and concerns by nonintensivists over lost revenue.

This landscape is changing rapidly though. In November 2000, the Leapfrog Group published a standard regarding Intensive Care Unit Physician Staffing (IPS).¹⁶ The Leapfrog Group is a consortium of Fortune 500 companies and other large health care purchasers committed to a common set of purchasing standards. The standards, which were fully implemented in 2003, define expectations for critical care physician services that are consistent with the closed ICU model of care. As a result, their adoption creates an increased demand for intensivists.

The current anticipated need cannot be met with the projected available workforce. It has been estimated that 35,000 critical care physicians will be required to staff all adult U.S. ICUs.² The current supply is about 9,500. This deficit of providers, coupled with the aging population and increased acuity of inpatients in all adult hospitals and in extended care facilities, mandates a re-evaluation of our training programs and models of care. First, we should evaluate the anesthesiology residency curriculum to determine if we are training the providers that will be required, if they will have the skills necessary to deliver the care that future generations will expect and if we should redefine the specialty, much as pulmonary medicine has done, and embrace critical care as an integral part of the practice of anesthesiology. In addition the need for alternative models of care in the ICU provides an opportunity for our specialty to take another leadership role, building on our traditions.

Anesthesiologists have done an outstanding job of utilizing nonphysician, mid-level providers as part of the anesthesia care team to continue to deliver high-volume, high-quality, efficient care. As such the specialty of anesthesiology, given its historical roots in CCM, is the ideal profession to help solve the delivery of care crisis in critical care.

Finally we will have to think about how the pressures of a critical care practice and the career expectations of our trainees can be simultaneously addressed. Full-time careers in CCM are limited by long hours, emotional and physical challenges, unpredictable work patterns, potentially lower remuneration and politics. We do not believe each and every anesthesiologist should be able to practice as an intensivist, just as the specialty does not expect every member to practice pain management or perform echocardiography. Rather we propose that each department or group have a subset of practitioners who do function as intensivists for some portion of their professional activities. This group of providers, however, must be seen as integral to the department and must work collaboratively to fulfill patient needs in the O.R. and ICUs. The incorporation of other providers, including acute care nurse practitioners and other physician extenders, will improve care delivery and make a long-term career in critical care both rewarding and viable. Initial studies of such collaborative, medically directed models indicate that this paradigm is clinically efficient and effective in some patient populations.^{17, 18}

Like our parent specialty, anesthesiology, economic issues are of major importance to the practice of CCM; a substantial percentage of patients treated in ICUs are covered under Medicare, and that percentage is expected to grow as the population ages. The Critical Care Workgroup addresses these issues with the Centers for Medicare & Medicaid Services and includes these six organizations: the American Society of Critical Care Anesthesiologists, the American College of Chest Physicians, the American Association for the Surgery of Trauma, the American Thoracic Society, the National Association for Medical Direction of Respiratory Care and the Society of Critical Care Medicine. With regard to reimbursement, the relative value unit for critical care services was recently increased and the definition broadened to include both treatment and prevention of major organ dysfunction.

Over the coming years, as the population ages and an increased number of individuals survive with chronic diseases, tertiary-care centered hospitals are likely to increase the percentage of critical care and monitored beds to upward of 50 percent of the total. In addition much of what is now described as acute inpatient care may be transitioned to ambulatory care, leaving the hospital an even more high-intensity environment that will require the expertise of the critical care practitioner. The combination of a sicker patient population, coupled with the payer-driven demand for quality care, will result in significant demands for future critical care practitioners. Likewise these same changes will require all anesthesiologists, whether “intensivists” or not, to broaden their skill-set to continue to provide optimal care for these high-acuity patients. Whether the majority of critical care services will be delivered by physician intensivists or whether we will expand the pool of other providers working collaboratively with critical care-trained physicians, the opportunities for our specialty to regain its preeminent role in critical care is outstanding — if we take advantage of it.

As described by Ronald D. Miller, M.D., Chair of the ASA Task Force on Future Paradigms of Anesthesia Practice,¹⁹ the future of intraoperative anesthesiology practice may change significantly, and our perceived deficit of “providers” may, in fact, be wrong. Likewise, during his outstanding Emery A. Rovenstine Memorial Lecture at the ASA 2005 Annual Meeting in Atlanta, Mark A. Warner, M.D., challenged us to embrace the changing profession of anesthesiology as our skills become resourced to the most critically ill patients in the O.R. and ICUs.

The challenge is before us: How we choose to embrace it is another question.



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Gerald A. Maccioli, M.D., F.C.C.M., is ASA Director for North Carolina, and Director of Critical Care Medicine, Critical Health Systems of North Carolina, Raleigh Practice Center, Raleigh, North Carolina.

Neal H. Cohen, M.D., F.C.C.M., is Vice-Dean, School of Medicine, Professor of Anesthesia and Medicine, and President of the University of California-San Francisco Medical Group, University of California-San Francisco, San Francisco, California.