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Developed by: Committee on Critical Care Medicine
Original Approval: October 18, 2023
Authors: Brigid C. Flynn, MD; Megan H. Hicks, MD; Craig S. Jabaley, MD; Shawn T. Simmons, MD, FASA; Courtney L. Maxey-Jones, MD; Vivek K. Moitra, MD; Daniel R. Brown, MD, PhD; Ashish K. Khanna, MD, MS, FCCM, FCCP, FASA; Brent Kidd, MD; Jarva Chow, MD, MPH, FASA; Shweta Yemul Golhar, MD; Kaveh Hemati, MD; Talia K. Ben-Jacob, MD; Margit Kaufman, MD, FASA; Miguel Cobas, MD; Michael Nurok, MBChB, PhD, FCCM; George Williams II, MD, FCCM, FCCP, FASA; Mark E. Nunnally, MD, FCCM
While there is copious literature concerning the medical practice of critical care, there is very little updated literature concerning the physician practice, administration, and management of critical care. Furthermore, there is an extreme paucity of data concerning anesthesiology critical care. Of the nearly 30,000 privileged intensivists in the United States, anesthesiology intensivists are estimated to make up less than 5%,1,2 however, the exact number of anesthesiology intensivists is unknown. What is known is that the number of anesthesiology critical care fellowship applicants is far less than fellowship positions available and, thus, sustainability of anesthesiology critical care requires a redoubling of efforts.
Written by practicing anesthesiology critical care physician experts, this statement has several aims that heretofore have been relatively undocumented. Firstly, this consensus statement attempts to call attention to the training path and current practice models of critical care anesthesiologists. Secondly, we investigate the shortage of anesthesiology intensivists, especially women, and offer suggestions on improving this. Thirdly, we examine and compare reimbursement of critical care and anesthesiology care. Next, we attempt to elucidate how full-time equivalency for an anesthesiology intensivist is defined. Finally, we aim to bring forth opportunities on how to maintain the relevancy of anesthesiology critical care in health care systems.
Anesthesiology intensivists practice in various types of intensive care units, including medical, surgical, and burn ICUs. Many anesthesia anesthesiology intensivists practice in more than one type of ICU, but overall, approximately 70% of anesthesiology intensivists practice in cardiothoracic surgical ICUs. The remaining 30% work in surgical ICUs (50%), mixed medical/surgical ICUs (25%), and neuroscience ICUs (20%).1,2
Anesthesiology intensivists are formally trained in all aspects of critical care medicine and can evaluate and treat all populations of critically ill patients in any type of ICU. However, unique from other critical care training pathways, anesthesiologists acquire an intimate knowledge of the management, physiologic stresses, and complications of patients during the peripartum, surgical, and perioperative periods. These contextual factors have strongly contributed to a predominantly surgical critical care practice for anesthesiologists in many healthcare organizations and limited opportunities in other critical care settings (e.g., medical) despite robust training in the care of all critically ill patients.
Prior to a year of critical care fellowship, anesthesiology residents are required to complete (1) a minimum of 4 months of critical care, (2) a minimum of 2 months of cardiothoracic anesthesia anesthesiology, and (3) proficiency training in basic transthoracic and transesophageal echocardiography skills by the end of the anesthesiology residency. These are minimum requirements, and many residents and fellows obtain more experience than required.3
2. What are common models of anesthesiology critical care in academic centers?
A 2023 survey of members of the Society of Critical Care Anesthesiologists (SOCCA) identified that more than 76% of anesthesiology critical care physicians practice in academic settings in tertiary medical centers.1 The remaining 23% work in non-academic or private practice settings. The vast majority of respondents report supervising residents, fellows, and advanced practice providers (APPs) and rounding with multidisciplinary teams, including other physicians, pharmacists, and respiratory therapists. Only 2% of respondents work independently without these additional supervisory roles.
Approximately 90% of respondents spend time working in both the operating rooms and ICUs with most respondents working approximately 50% of their clinical time in each.1 However, when covering the ICU, most anesthesiology intensivists (86%) were not responsible for other anesthetizing locations. Most respondents identified working 4 to 7 consecutive days in the ICU, averaging 60 to 90 hours per week and reported covering the ICU 10 to 15 weeks per year.2 Approximately half of anesthesiology intensivist groups provided in-house 24/7 coverage, and half provided ICU care with a day shift and nightly home call coverage model. The median number of beds covered by one intensivist was 14 beds during daytime hours and 26 beds overnight.
In academic medicine, it is common for anesthesiology intensivists to have structured post-call time free of clinical responsibility following weeks of ICU coverage in order to allow for recovery following these physically and emotionally demanding weeks. Anecdotally, this time ranges from 2-7 days of post-ICU time per week of ICU coverage.
3. What are common models of anesthesiology critical care in private practice?
Dual anesthesiology and critical care positions are less common in private practice (either a private group or a national staffing company) compared with academic settings. A recent survey-based analysis found that 76% of anesthesiology critical care physicians practice in academic environments and 23% in private practice environments.1
From the standpoint of a private practice financial model, revenue generation from anesthesiology operating room professional service is, at face value, more financially productive than critical care anesthesiology professional services. This disincentivizes private groups from offering critical care services. Thus, critical care services in private practice are often financially supported by a hospital stipend in order to decrease the perceived financial loss.2 (See also question 8.) Alternatively, while private practice anesthesiologists are employed by the private group, anesthesiologists practicing critical care may be employed by the institution. This model requires private practice anesthesiology intensivists to be either part time for two employers or to only work critical care or anesthesiology shifts during vacation time from their respective full-time position.
Additionally, in many private practice groups, the call burden of ICU care, which usually requires some type of night and weekend coverage, is a large burden on top of the general anesthesiology call. As an example, many private practice intensivists work 7 days consecutively with 7 days of postcall time. If only providing critical care, this would equate to a total of approximately 24 clinical weeks per year (excluding vacation weeks). In contrast, private practice anesthesiologists typically work approximately 44 clinical weeks per year (excluding vacation weeks). This disparity in scheduling may not be seen as equipoise to members of a group. Thus, private practice anesthesiology critical care requires group support when offering critical care coverage.3
Another difference concerning private practice anesthesiology critical care is the type of ICU typically covered. Medical ICUs or community hospital mixed ICUs are common units.4 Telemedicine ICU opportunities are another option available in private practice, however, careful attention must be paid to ensure there is not overlap between telemedicine coverage and intraoperative anesthetic care.
4. Is 24/7 in-house intensivist coverage optimal for an ICU?
Addition of nocturnal coverage, in addition to daytime ICU coverage, is commonly referred to as 24/7 in-house intensivist care. A 24/7 model has the potential to enhance patient care, however there is debate in the literature concerning this. Overnight in-house intensivists can provide oversight of the ICU team, allow for extension of care processes, identify appropriate bed utilization and triage, help with end-of-life care planning, and provide procedural skills. These tasks could lead to enhanced patient outcome benefits and ICU efficiencies. Economic modeling of 24/7 ICU staffing that falls just short of mandated attending presence at night suggest there is an opportunity for savings totaling millions of dollars for an ICU.1
Benefits in reduced complications2,3 and length of stay4 are suggested in the literature. Adherence to care processes, such as stewardship of blood products or reduction of ventilation time,2,3 has also been shown to be improved with 24/7 coverage. However, mortality benefit is not commonly seen when ICUs transition to 24/7 coverage and, hence was not seen in the latest American Thoracic Society recommendations.2,3,5.6,7 Notably, these studies were performed in medical or mixed ICUs and specific patient outcomes may be more evident in high acuity and high turnover ICUs, such as cardiothoracic ICUs.8 Finally, evidence suggests overall improved satisfaction among ICU teams who provide 24/7 physician staffing.5 However, the burden of additional night shifts must be weighed individually as other data find rotating night shift work to be associated with decreased probability of healthy aging.9,10,11
In-house 24/7 coverage increases the burden of weekend and night shifts with staffing requirements more than doubling from a home call model. Financially, these shifts require financial compensation for the physician. However, there are fewer billing opportunities at night, so reimbursement cannot be expected to offset the added salary cost. The facilitation of optimized patient outcomes and ICU efficiencies may help in off-setting financial constraints. These benefits are difficult to measure, but are advantageous not only for individual patients, but also are relevant to ICU ratings, safety scores and possibly insurer reimbursement.
Other factors that are important when deciding if 24/7 coverage is the correct model for an ICU include the staffing of other clinical team members, clinical capabilities in the hospital at night,11 the empowerment of the various providers to practice to their expertise, and the quality of care pathways and protocols that do not require direct physician input.
5. How can we increase women in anesthesiology critical care?
Since 2019, women comprise the majority of medical school matriculants.1 However, women represent only 25-37% of the anesthesiology workforce and one third each of anesthesiology residents and critical care fellows.1,2 Only 11.5% of anesthesiology department chairs are women.3 Surprisingly, in 117 years since inception of the American Society of Anesthesiologists (ASA), only five women have served as president.4 These statistics are likely due to the attrition rate from medicine for women at a rate of 1.25 times that of men.1 Strikingly, a recent survey found that an overwhelming 90% of female anesthesiologists feel that women in medicine must work harder than men to achieve the same career goals.4
Approximately 26-30% of practicing intensivists are female.5 One reason for this gender disparity may be found in studies demonstrating that trainees with concerns regarding fertility and work-life balance are more likely to consider fields other than surgery and anesthesiology because nonprocedural fields are perceived to be more lifestyle-compatible.6 Indeed, 42% of female anesthesiologists reported limiting their practice because of stress in the home.4
Additionally, in a survey study of 502 female anesthesiologists, 51% reported that they limited the number of children they had due to career choices.4 These findings are consistent with a survey study on female cardiothoracic anesthesiologists in which 67% of respondents identified having children as having a negative impact on career advancement.7 Certainly, intensive care work is one of the most physically and time-demanding careers in anesthesiology, especially in the types of ICUs where anesthesiologists tend to practice.
To assist with child rearing and other barriers, societal support from Women Anesthesiologists in Critical Care (WICC), a subcommittee of Society of Critical Care Anesthesiologists (SOCCA), Women in Cardiothoracic Anesthesiology (WICTA), a subcommittee within the Society of Cardiovascular Anesthesiologists (SCA), and the free-standing group of Women in Anesthesiology (WIA) assist in matters of well-being and academic endeavors. In 2018, the American Society of Anesthesiologists published a Statement on Personal Leave.8 This was followed by the SOCCA publication of SOCCA's Recommendations for Parental Leave and Lactation, which focused on specified recommendations for anesthesiology intensivists.9 These recommendations encourage adequate parental leave and lactation support for new parents. This is in contrast to a recent survey of women in anesthesiology finding that 35% of institutions do not offer paid maternity leave.4
Another strategy to recruit more women to the anesthesiology critical care workforce is to analyze compensation disparity among genders. A 2023 SOCCA survey study reported that the mean compensation for female anesthesiology intensivists was $36,739 less than for male anesthesiology intensivists.5 However, after adjusting for age and academic versus nonacademic practice type, this difference was no longer significant (mean difference, –$27,480; 95% CI –$57,233 to $2273; p = 0.07).
Finally, workforce models that allow distinct separation of work and home as well as predictable hours, i.e., shift-based rather than home pager call models may improve work-life balance and be more enticing to the female intensivist.10
6. How can we increase underrepresented minorities in critical care anesthesiology practice?
To date, only one survey has been conducted attempting to elucidate racial demographics of critical care anesthesiologists.1 A SOCCA membership survey found that the field of critical care anesthesiology currently lacks diversity with most anesthesiology intensivist respondents identifying as white (73%) and male (69%). This male gender composition mirrors an American Society of Anesthesiologists Critical Care Committee survey of anesthesiologists with critical care board certification which found male gender to represent 72% of respondents.2 Racial and ethnic disparities in the workforce are evident in academic medicine. Physicians form black and Hispanic backgrounds comprise only 6% of full-time academic physicians, despite comprising 31% of the US population.3
Increasing diversity in the subspecialty of anesthesiology critical care will require a team effort with leadership support. Firstly, recognizing the value of a diverse workforce is necessary. Diversity among teams improves team performance, increases cultural humility, and fosters innovation. Importantly, patients benefit from a diverse healthcare workforce due to enhanced access to care, reduced health disparities, improvements in quality of care for underserved populations, and improved patient compliance and satisfaction.4 Additionally, diversity in the healthcare workforce improves research quality as diverse research teams broaden the scope of research questions, priorities, and participant enrollment.4 Thus, investment in workforce diversification is beneficial on many institutional levels.
In order to increase the number of underrepresented minorities in anesthesiology critical care, appointing a person(s) who champions the mission of creating diversity, such as a Diversity, Equity and Inclusion (DEI) team leader, can be of great value in ensuring the mission of diversity is thoughtfully enacted. The DEI leader may need additional training in this area and should be sponsored to attend outsourced training courses as needed. Departmental initiatives, including implicit bias education, can be of great benefit to teams. Obviously, ensuring salary equality among underrepresented minority intensivists must occur.
Perhaps the best way to promote a diversified critical care profession is for institutions to model a diversified critical care team by example.5 Most people want to work in environments where they don’t feel like an outlier. By having underrepresented minority intensivists on staff, it may be easier for underrepresented minority applicants to envision themselves within the group. To do this initially, recruitment of these candidates needs to occur, which can be led by a DEI team leader, division director, or department chair.
Recruiting underrepresented minorities can be encouraged with mentoring and career development programs initiated during a trainee’s medical school and residency years. Exposure to anesthesiology critical care during these formative years via various formats can be an effective intervention to engage the interest of underrepresented minority trainees. Thereafter, focusing on faculty retention and promotion of underrepresented minorities will aid to sustain diversity.6 Creating and maintaining diversity in anesthesiology critical care will require intentional and collaborative efforts that will ultimately benefit patients, staff, trainees, and society.
7. How can we increase anesthesiology trainees' desire to enter critical care fellowships?
There are comparatively fewer anesthesiology intensivists in the United States than in European health care systems. In the United States, pulmonary and surgery intensivists more commonly fulfill critical care needs within hospitals.1 The COVID pandemic allowed for anesthesiologists around the world to demonstrate proficiency in complex ventilator management, other facets of acute care management, and procedural skills.2
Indeed, applications to anesthesiology critical care fellowships reached an all-time high in 2021, perhaps due to critical care exposure during the pandemic. Figure 1 demonstrates that applications to anesthesiology critical care fellowships have decreased since then to a decade long nadir in 2023. Of the 225 anesthesiology critical care fellowship positions offered in the 2023 match cycle, only 136 were filled with 145 applicants. Yearly, the number of applicants has been lower than the number of positions available with this gap widening as the number of fellowship positions and programs have increased.3
Figure 1. Anesthesiology critical care training fellowship programs, positions and applicants from 2014 to 2022 from the American College of Critical Care Medicine (ACCM). Of note, not all applicants are anesthesiologists with some being residents from other specialties. Available at STmatch.org.
A survey conducted across all anesthesiology programs across the U.S. identified themes as to why many anesthesiology residents do not choose critical care fellowships.4 The following were cited:
In order to make anesthesiology critical care more appealing to the residents, experts have suggested several possibilities.3 These include earlier exposure to anesthesiology critical care, possibly at the medical school level. This would also allow for early identification of interested medical students enabling rotation guidance germane to critical care. Also, facilitating further critical care electives during residency would increase exposure and potentially lead to increased autonomy with experience. Additionally, creating awareness for critical care ultrasound training and certification could garner interest and excitement. In fact, the implementation of simulation sessions with critical care scenarios in addition to point-of-care ultrasound training has been shown to increase interest in anesthesiology critical care medicine among several anesthesiology residents and medical students across the country. Continuing these exposures to trainees can serve to amplify the interest in anesthesiology critical care medicine.
Raising awareness of chronic and terminal care and the profound effect it has on patient care and satisfaction is another goal. Facilitation of appropriate training concerning death and communication around withholding and withdrawing care is a skill seldom used in the ORs. Hence, proper training concerning emotionally challenging scenarios will help allay anxiety in the ICU. Additionally, focus on humanistic aspects, such as wellness, collegiality, communication, coping, research and administration need to be implemented to better serve anesthesiology trainees.5
Attention to resident and fellow duty hours is important in facilitating interest and avoiding trainee burnout. Staffing and clinical models incorporating advanced practice providers (APPs) to assist in patient care responsibilities may allow time for educational opportunities.
It is also suggested that programs could increase social media presence in order enhance outreach to a younger audience. Outreach could also be enhanced with heightened visibility at the American Society of Anesthesiologist meetings.
Lastly, some experts propose increased positions for combined five-year anesthesiology residency and critical care tracks to facilitate integration of clinical skill and knowledge. The unique integration of clinical skill and knowledge that these combined programs provide develops physicians who are well positioned to be leaders in both anesthesiology and critical care medicine. Institutions with combined training programs have effectively cultivated and stimulated trainees' enthusiasm, equipping them to emerge as leaders in anesthesiology and critical care medicine upon the completion of their training.
It has also been suggested that increasing interest in dual fellowship training, with possibly combined matches, by collaborating with other subspecialties, including emergency medicine, nephrology and infectious disease, may broaden the pool of applicants.
8. How is critical care anesthesiology paid?
According to the American Medical Association’s Current Procedural Terminology (CPT) handbook, critical illness is defined as an illness that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration". Critical care codes are time-based codes that are independent of history, examination, and decision-making documentation and meant to reflect time spent on billable critical care activities, which include: direct patient care, coordination of care, interpretation of diagnostic tests, documentation of medical decision-making, and other pertinent activities. Critical care billing includes interpretation of monitors, chest radiography, and mechanical ventilation management, which cannot be billed separately. Time spent reviewing laboratory test results or discussing the critically ill patient’s care with other medical staff in the unit or at the nursing station on the floor can be reported as critical care time.
There is a minimum of 30 minutes of critical care services required to bill the first tier of critical care billing, or 99291. While this time does not need to be continuous, the provider must give their full attention to the patient and be immediately available. Institutions are reimbursed for the billed time differently based on the patient's insurance carrier, namely a commercial payor versus Centers for Medicare and Medicaid Services (CMS)(Tables 1 and 2).
CMS establishes payments via relative value units (RVUs) that consider the resources to furnish a service. Total RVUs are calculated by adding the work RVU, the practice expense RVU, and the malpractice RVU together.
Physician work (work RVU or wRVU) reflects the time and intensity to provide a service. Practice expense (PE RVU) reflects the cost to practice (overhead, equipment, etc.). Malpractice expense and professional liability insurance (PLI RVU) reflects the cost of malpractice insurance.
The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) adjusts all three components by geographic location via the geographic practice cost index (GPCI):
Total RVU = Work RVU x Work GPCI + PE RVU x PE GPCI + PLI RVU x PLI GPCI
These adjustments are intended to account for differences in the cost of care across different geographic localities such that higher cost areas have higher GPCI adjustments.
The Medicare payment for a CPT code (e.g., 99291 for first tier of critical care billing) is calculated based on the Medicare Physician Fee Schedule (MPFS) which determines the total RVU for a CPT code and multiplying the total RVU by a conversion factor.1 A 99291 service has the following base RVUs: work RVU, 4.5; PE RVU, 1.39; PLI RVU, 0.42; and total RVU: 6.31.
It’s important to note that the RVU value can change annually based on updates to the Medicare Physician Fee Schedule. For example:
CMS Payment in 2023 = Total RVU x the CY 2023 Conversion Factor of $33.8872
For comparison, the commercial payor conversion factor for critical care is approximately $89. Another difference in CMS versus commercial payor reimbursement is the time required to achieve the next billing tier. For CMS, effective in 2023, 106 minutes of critical care time must be documented prior to moving from the 99291 first tier of billing into a 99292 (Tables 1 and 2). This is compared to 75 minutes of documented critical care time for commercial payors, although prevailing CMS guidance may ultimately serve to prompt changes by commercial payors.
Table 1. Critical care documented time Medicare/Medicare schedule
| Total Duration of Critical Care | Code(s) |
| Less than 30 minutes | Bill appropriate E/M |
| 30 minutes - 104 minutes | 99291 x1 |
| 105 minutes - 135 minutes | 99291 x1 and 99292 x1 |
| 136 minutes - 166 minutes | 99291 x1 and 99292 x2 |
| 167 minutes - 197 minutes | 99291 x1 and 99292 x3 |
| 198 minutes - 228 minutes | 99291 x1 and 99292 x4 |
Table 2. Critical care documented time and commercial payor schedule
| Total Duration of Critical Care | Code(s) |
| Less than 30 minutes | Bill appropriate E/M |
| 30 minutes - 74 minutes | 99291 x1 |
| 75 minutes - 104 minutes | 99291 x1 and 99292 x1 |
| 105 minutes - 134 minutes | 99291 x1 and 99292 x2 |
| 135 minutes - 164 minutes | 99291 x1 and 99292 x3 |
| 165 - 194 minutes | 99291 x1 and 99292 x4 |
Billing for procedures is another way to create RVU generation. During residency and fellowship, anesthesiology intensivists become proficient at numerous billable procedures, such as arterial lines, central lines, pulmonary artery catheterization, bronchoscopy, echocardiography, extracorporeal membrane oxygenation (ECMO) management, cardioversion, and left ventricular assist device (LVAD) interrogation. Some anesthesiology intensivists provide ECMO cannulation and intra-aortic balloon placement.
9. Does a day in the ICU equate financially to a day in the operating room for an anesthesiologist?
Anesthesiology departments who support critical care services are required to understand the compensation differences between anesthesiology services and critical care services. In order to do this, department financial planning consists of several data points:
For comparison, anesthesia care is billed by utilizing three components: 1) anesthesia base units, 2) time units in 15-minute increments and a 3) payor specific conversion factor. Anesthesia care is reimbursed differently depending on the level of care provided by the billing anesthesiologist. Medicare pays 100% for personally performed physician care, teaching, and medically directed cases, however this decreases to 50% for medically directed cases. The APP being medically directed receives the other 50% of the fee, so when the APP being medically directed is a member of the same anesthesia group, the full fee is collected by the group.
Anesthesia reimbursement is further dependent on the speed of the surgeons, room turnover time, procedure complexity and payor mix. These are factors frequently outside the anesthesiologist’s control.
10. How can we measure a critical care full time equivalent (FTE)?
A full time equivalent (FTE) is a useful metric to determine workforce requirements, set compensation, and schedule clinical work. When organizing a critical care service, the FTE concept is additionally helpful in establishing the relationships between work in the ICU and in the OR or other venues where multispecialty critical care physicians might practice.
Time is a critical factor in determining an FTE. In a recent survey of anesthesiology critical care practices, most respondents reported working 10-15 weeks in the ICU a year, presumably equating to 0.5 FTE.1 When covering the ICU, respondents reported working 60-90 hours per week. Another survey that included multiple physician specialties practicing critical care reported a median of 24.1 weeks per year (range, 19-28 weeks) as 1.0 FTE.2
These data simplify time worked as a surrogate of FTE. Notably, this is independent of staffing models. In an ICU with 24/7 attending in-house coverage, every hour is covered by an attending physician. Conversely, models without 24/7 in-house presence would require significantly fewer FTE, but must account for patient management in the absence of a bedside intensivist. Lastly, time used as a surrogate does not reflect the intensity and desirability of the shift. Nights and weekends can be more intense and less desirable and, thus, may need to be valued more highly than a day shift. While 20-30 weeks per year may be a reasonable range for 1.0 critical care FTE, the nature of shifts significantly impacts sustainability.
Productivity models are common in various clinical FTE calculations. Most frequently, productivity is measured in Relative Value Units (RVUs), which are assumed to account for the complexity and intensity of clinical practice and are the basis for billing.3 RVUs may be helpful for budgeting purposes where a hospital or department uses RVU quantity as a surrogate of FTEs required for a service based on the volume and complexity of patients. However, RVU quantity should not be used to measure the performance of critical care faculty for the following reasons. RVUs in critical care are mostly time-based codes and procedure codes not directly reflecting the factors used to determine RVUs, specifically the intensity of service provided in a specific patient. Further, models that use RVU production to set compensation may create perverse incentives to over-utilize ICU resources and perform additional procedures.
Other obligations may influence what constitutes an FTE.4 Administrative duties ranged from less than 5 to greater than 20 hours per week in a survey of multiple physician specialties practicing critical care. These duties could include leadership roles, family meetings, facilitating processes of care, along with non-billable activities such as covering rapid response teams and assessing patients for admission to the ICU. Teaching and supervision are important components of many critical care practices, and in some models constitute a large amount of time on the part of the attending physician. Many departments use a "time percentage" of these activities counted as work toward a full-time FTE.
11. How can we foster investment of critical care anesthesiologists in their groups and promote leadership in a group through faculty development?
As leadership roles evolve, compartmentalization of career trajectories often occurs in order to seek excellence. For critical care anesthesiologists, these areas of excellence could be clinical, education, research or administration. While each of these areas demands training and development, none are truly independent of each other. Thus, it is hopeful that future critical care anesthesiology leaders do not focus on one niche at the cost of another area of excellence.
It is incumbent on current leaders to develop and direct trainees and junior faculty to embrace numerous areas of excellence. Every critical care anesthesiologist will naturally gravitate towards a specific area, reflecting their unique talents and passions. However, during their formative years, it's essential to foster a balanced environment that doesn't favor a single role, such as research, at the expense of others like administration, clinical work, or education. Leaders of tomorrow in critical care anesthesiology should be well-rounded and ready to advance all aspects of the mission and vision of the institutions they serve, as well as the broader perspective of an intensivist. This goal may seem lofty but will pay dividends in the future and contribute to the longevity of the specialty of critical care anesthesiology.
While there is not a singular identified plan to best develop a truly well-rounded critical care anesthesiologist leader, there are some general principles. First, there should be exposure to all career pathways starting in fellowship. There should be a general expectation in training programs that some level of competence for all pathways be achieved for graduating fellows. This would continue into promotion of junior faculty. Second, mentorship from senior and mid-career faculty who have excelled at multiple aspects of the specialty should be encouraged. This can include time with faculty at outside institutions. Third, senior staff should advocate for trainees and junior faculty to have meaningful positions on committees and projects, especially with cross collaboration among other departments. Table 1 identifies possible roles.1 Taking mentorship one step further and assisting in getting junior staff involved in national academic societies is important. Lastly, critical care division chiefs need to advocate for critical care staff to be mentored by research leaders, operations chairs and department chairs not only within, but also outside of their institution.
Table 1. Leadership opportunities in modern anesthesiology ICU teams.1
12. How can we solidify anesthesiology intensive care groups in a health system?
Critical care programs staffed either exclusively or in majority by anesthesiologists vary extensively in their size and scope nationwide. Survey data suggest that the majority of practicing critical care anesthesiologists staff surgical and other high complexity ICUs within tertiary academic healthcare settings.1 This current state may, at least in part, reflect the historical precedent wherein large healthcare systems hosting reputed anesthesiology training programs developed robust fellowship programs in critical care medicine and associated faculty practices. Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) mandates that “faculty anesthesiologists experienced in the practice and teaching of critical care” must be actively involved in clinical care and education.2
As of 2022, a manual review of 152 accredited anesthesiology residency programs yielded only an estimated 106 programs with associated active anesthesiology critical care medicine practices.3 The myriad factors contributing to this gap are poorly understood, but as previously reviewed, conceptual contributors include challenges pertaining to the pipeline of interested trainees, reimbursement, and competing clinical demands amidst changing anesthesiology workforce demographics. Each of these pressures has undergone rapid evolution within the past five years, and in response anesthesiology critical care medicine programs must work to build and solidify their respective strategic positions.
More broadly, the past three decades have been marked by gradually more hospital or organizational subsidization of clinical anesthesiology services owing to a combination of complex factors, including dwindling payor reimbursement for professional services, changing payment models (e.g., bundled), a competitive labor market, and increasing clinical complexity of the surgical patient population.4 In this vein, anesthesiology and critical care medicine are often similarly perceived as cost centers rather than profit centers. Just as anesthesiology practices have increasingly needed to understand and answer the changing needs of their parent organizations amidst financial pressures and cost subsidization, critical care medicine practices must act similarly.
As critical care medicine is distinctly hospital-based, experience in building successful partnerships is of critical import and often a strength of anesthesiology practices amidst other hospital-based services. Anesthesiology critical care medicine practices are often further uniquely advantaged in that they support high margin service lines, such as complex surgical procedures. These strengths are sometimes counterbalanced by the practical reality that critical care differs distinctly from anesthesiology, requiring adaptation of established approaches. Recognizing that critical care medicine is distinctly hospital-based, that most anesthesiology critical care medicine practices appear to be situated in tertiary academic centers, and that modern critical care medicine is multidisciplinary, clinical and administrative leaders in critical care must be facile in organizational diagnosis and cultivate omnidirectional influence within increasingly complex organizational matrix structures to be effective.5 Such leaders must be empowered by virtue of skills development, protected time, and the (formal or informal) authority to champion the wellbeing and development of critical care practices in parallel to other strategic initiatives that are of primary import to the anesthesiology practice.
Understanding the interests relevant to critical care services of a hospital or healthcare system is paramount. While these are variable, key themes often emerge: timely access to care, resource stewardship, team development, quality, and, increasingly, population management as healthcare systems expand into the community. Critical care anesthesiologists can easily cross departmental barriers by being integral parts of health system level teams, such as blood management and antibiotic stewardship task forces and creating quality pathways such as lung protective ventilation and sedation practices. Leadership in hospital bed allocation is another area germane to critical care anesthesiology. These interests must then inform relevant goals, development of strategies, and ultimately execution by empowered critical care leaders and their teams.
For example, hospitals struggling with timely access to critical care would likely benefit from a critical care consult service or a similar approach to critical care “without walls.” Healthcare organizations struggling with critical care in the context of physical expansion would likely benefit from clinical coverage of community sites and/or tele-critical care programs. While the “what” or “how” in this evolution can be variable, the end products and signs of success are perhaps more similar: a well-supported, sustainable critical care practice organized in keeping with the best principles elucidated previously.
Hospitals or healthcare systems with multiple, subspecialized ICUs have historically approached practice organization according to traditional silos: medical ICUs spearheaded by pulmonologists, medical cardiovascular ICUs spearheaded by cardiologists, and so forth. These siloed organizational structures are familiar to clinicians and leaders but do not necessarily directly benefit patients, hospitals, or the broader critical care practice. Critical care organizations (CCOs) offer a potentially appealing alternative to these traditional structures wherein horizontal and vertical integration of the critical care practice can be centrally championed.6,7 To an anesthesiology critical care practice, the development of a CCO may be initially perceived as risking loss of autonomy. However, CCOs may also serve to strengthen organizational support, offload certain administrative and quality-related tasks from the department, bolster the academic mission, and offer clinical practice opportunities not typically afforded to anesthesiologist intensivists.8
For individual anesthesiologist intensivists, CCOs can afford a more diverse array of leadership opportunities within critical care and more direct line of sight into organizational priorities and exposure to organizational leaders. Indeed, anesthesiologists are accustomed to, and skilled at, working across traditional professional silos and navigating other complex hospital-based administrative structures, which are key skills for any critical care leader.
Date of last update: October 19, 2023
