Jul 082018

Intensivists may get all the credit, but over 37,000 hospitalists provide much of the care for ICU patients in the U.S.

According to a recent survey, they often do it without the presence or availability of intensivists for consultation or support, especially outside urban centers. The internists aren't happy about it, feeling uncomfortable, unsupported and forced to practice beyond their scope of training and expertise.

Authors surveyed practicing hospitalists in the U.S., about three-quarters from community hospitals and a quarter from academic medical centers. There were 425 responses:

  • Almost all hospitalists in rural-based medical centers reported they provide ICU care, and half of them said they delivered all the ICU care at their hospitals.
  • Fully 17% (about 1 in 6 responding) said they had the primary responsibility for managing mechanically ventilated patients at their centers.
  • More than 75% of all responding hospitalists said they delivered care in ICUs.

They did it because they had to: frequently, no intensivist was consistently available to help. About 75% of hospitalists said they felt they did not have appropriate support by intensivists. More than a third reported feeling they were being forced to practice outside their scope. Close to 9 in 10 said they would be willing to undergo specialized training in critical care, as long as they did not have to leave practice to return to a formal training program.

A current or impending nationwide shortage of intensivists has been periodically announced over the past 20 years. The shortfall has been challenged on the grounds that most patients admitted to U.S. ICUs are not truly critically ill. But numerically speaking, it's undeniable.

There just aren't enough pulmonologist-intensivists to staff every medical ICU in the U.S. -- and certainly not for the 24 hours a day advocated by some. Anesthesiologists, emergency physicians and internists trained in critical care can help make up the gap, but like other specialists, they probably won't go to rural areas in sufficient numbers to solve the problem.

Telemedicine (e-ICUs), increased reliance on advanced practice providers, or the creation of transport networks diverting truly critically ill patients to urban medical centers have been suggested as alternative models of care to meet the expected need. Advanced critical care training courses could be provided (by professional societies or universities, e.g. in weekend CME every few months over a few years) to hospitalists who must care for critically ill patients without adequate local intensivist support.

Sources: J Hosp Med, Society journal articles 1, 2, 3

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Hospitalists Are the New Intensivists