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A marriage proposal: hospital medicine and critical care

June 2008

Hospitalists are certainly moving in the right direction when it comes to a tailored recertification process. What’s being billed as a focused recognition in hospital medicine will not require fellowship training, just two years clinical experience and an exam. I’m also hearing talk of reforming internal medicine residency programs to give physicians who want to become a hospitalist more focused training in inpatient care. Also a great idea, to my mind.

The ABIM is clearly busy doing things that make sense. So, here’s something else to add to the list: working to correct our intensivist shortage by combining a hospitalist-directed residency (or what is now simply the internal medicine residency) with a one-year fellowship in critical care.

Currently, the ABIM requires two years of critical care training for medicine graduates who have not completed a fellowship in another internal medicine subspecialty. Yet the clinical time required is exactly the same: 12 months, for doctors with or without fellowship training alike. Medicine-only training requires an additional 12 months of research–are you kidding me? We have a critical need for intensivists in the clinical setting, not lab work.

Moreover, there are many reasons why health care in the U.S. would be better served having more hospitalists board certified in critical care. First, hospitalists already play a vital role in critical care in community-based hospitals. Many of them partner with intensivists–while many others are the de facto intensivists, especially in rural areas.

It’s been my experience that most pulmonologists in community hospitals are happy to co-manage critically ill patients with hospitalists, often choosing to concentrate their practice on ventilator management. And in many 24/7 in-house hospitalist programs, it’s the hospitalists who function as the intensivist extenders at night.

After eight years as a hospitalist, I can count on one hand the number of times a pulmonary critical care physician has come to the ICU in the middle of night when they trust the in house hospitalist team. And I don’t blame them or any other specialist. Their financial incentives are such that they are much better compensated if they run a busy outpatient clinic, have their own PFT lab or run a sleep lab, while sleeping themselves. The math is compelling, particularly if these folks can rely on hospitalist colleagues to cover for them.

The point is, you don’t have to complete a two-year fellowship to practice good ICU medicine. And I certainly see no evidence that hospitalists who practice critical care have hurt our patients. (Remember, early critical care data compared intensivists to traditional rounders, not dedicated hospitalists.)

In fact, I was intrigued by the results of a study published earlier this month, which found that intensivists actually have higher rates of mortality in the ICU than non-intensivists, even when those rates are adjusted for severity of illness. The authors offered a few reasons why they may have ended up with such unusual findings. One of those reasons was that intensivists may be less familiar with individual patients than physicians who also care for those patients outside of the ICU.

The bulk of critical care does not require significantly more than applying–with care and attention to detail–the knowledge learned in internal medicine training.

Plus, consider what Dr. Peter Pronovost has demonstrated: using checklists in ICUs saves millions of dollars and thousands of lives. Hospitalists have a lot of experience with treatment protocols, in much the same way that we have made order sets for DVT prophylaxis the standard of care in our hospitals. Wider use of hospitalists–particularly if they have one year of intensivist training–may very well lead to broader implementation of these protocols in ICUs, outside of academic centers.

The current national ICU doctor shortage is only going to get worse as aging baby boomers are already bearing down on ICUs. And I doubt that eICUs by themselves are the solution.

While it is reasonable to send an X-ray to India to be read at 2 a.m., I doubt that closed circuit doctoring will provide comparable care to what is practiced at the bedside. (At least we won’t be spreading MRSA, though we run the risk of spreading a computer virus!) In many cases, eICU-doctors direct hospitalists who are on-site. Do we really need that redundancy in care?

I believe it is only natural to marry the two specialties. Yet the opinions that count come from teaching hospitals, which have the resources to maintain closed units. I won’t argue that a closed unit is not more efficient. But I have my doubts about how efficient those units are when you add in another layer of handoffs as patients are transferred out of the ICU to the hospitalist service.

I’m sure that many internal medicine residents planning to become hospitalists would jump at the opportunity to become boarded in critical care if a one-year fellowship existed. In fact many are jumping at hospitalist fellowships, which perhaps are a good idea. But wouldn’t that one year be better spent becoming a hospitalist/intensivist if that option was available?

I’m not holding my breath that this pragmatic approach to improving our ability to deliver critical care will become a reality any time soon. Yet given the shortage of intensivists, and the aging demographic that will increase the burden on ICUs, I believe there is real potential for a merger between hospitalist and critical care medicine.