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Fast track in critical care training?

November 2012

Published in the November 2012 issue of Today’s Hospitalist

TWO FACTS about critical care medicine today are not in dispute: First, there is a serious shortage of physicians trained to take care of critically ill patients. And two, hospitalists are usually the doctors who fill that void. But a debate is now raging over how hospitalists who may be drawn to critical care medicine should receive the training and credentials they need.

Earlier this year, the Society of Hospital Medicine (SHM) in conjunction with the Society of Critical Care Medicine (SCCM) put out a proposal advocating for a fast-track fellowship for experienced hospitalists. But almost immediately, other associations that also represent critical care physicians and nurses pushed back on that proposal. So far, there’s been no meeting of the minds.

The dueling points of view have, however, had at least one positive effect: Major critical care stakeholders are beginning to talk about what a competent intensivist needs to know. It remains to be seen whether both sides will agree on how long it would take hospitalists with some ICU experience under their belts to achieve that level of competence.

One year, not two
The SHM/SCCM proposal was published jointly in both the May/June 2012 issue of the Journal of Hospital Medicine and the June 2012 issue of Critical Care Medicine. It proposed an accelerated critical care fellowship pathway (sanctioned by the Accreditation Council for Graduate Medical Education) specifically for experienced hospitalists that would lead to full critical care board eligibility.

The proposed pathway would allow hospitalists who were previously trained in internal medicine and have a minimum of “three sequential years of prior hospitalist practice experience” to enter a “condensed one-year training program” in critical care medicine, rather than the standard two-year fellowship. To be eligible for the one-year pathway, hospitalists would also have to participate in the focused practice in hospital medicine recertification program through the American Board of Internal Medicine (ABIM). They would also have to complete “at least one meaningful hospital-based quality improvement (QI) initiative while still in practice.”

The authors of that paper noted that there are already several different certification pathways for intensivists, including one-year critical care fellowships for surgeons, anesthesiologists and internal medicine subspecialists. Evidence “strongly suggests,” they wrote, “that competent intensivists can be trained through disparate pathways to achieve equivalent outcomes.”

“If you complete an infectious disease, nephrology or pulmonary fellowship, critical care certification requires one additional year of training,” explains Eric M. Siegal, MD, the lead author of the SHM/SCCM proposal and an intensivist at Aurora St. Luke’s Medical Center in Milwaukee, Wis. Dr. Siegal and his co-authors believe that experienced hospitalists would be able to become competent intensivists with a single year of additional training.

“There are clinical and operational competencies that you learn as a critical care fellow that many experienced hospitalists have already developed in practice,” he points out. “These include navigating complex care issues with other specialists and working in a high-acuity, fast-paced environment.”

The wrong scope of practice
Dr. Siegal speaks from personal experience. In 2008, after working as a hospitalist for 11 years, he entered a two-year critical care fellowship program. He could handle the financial impact because of a supportive physician-spouse, and having a fellowship program in the city where he lived helped him avoid uprooting his family.

“Most hospitalists can’t abandon their income stream for two years,” he points out, “but our hypothesis is that more could do so for one year. We also think that many hospitals would subsidize their hospitalists’ incomes for a year if they returned as intensivists.”

Dr. Siegal was struck by the fact that despite his many years of relevant clinical and leadership experience, he was treated like a freshly graduated internal medicine resident, at least from a training perspective. “My attending physicians, all former colleagues of mine, frequently commented on the ridiculousness of treating me as just another critical care fellow,” he says.

Currently, 71% of hospitalists report working in ICUs. According to the 2011 Today’s Hospitalist Compensation & Career Survey, more than half of these hospitalists say they function as full-fledged ICU attendings, while most report not being required to call for critical care consults.

But according to Dr. Siegal, hospitalists’ growing exposure to critical care has a down side. “Hospitalists are increasingly providing care that they are not necessarily qualified to render,” he points out. “We have a very heterogeneous hospitalist workforce that is being asked to manage everything from soup to nuts in the hospital. Why do we assume that people who have not received extensive critical care training are going to be consistently good at it?”

Other options
But hospitalists in the ICU are a reality and, due to supply-and-demand pressures, one that’s likely to persist. So how should non-intensivists be trained to do intensivist work?

Offering a shortened critical care fellowship is one idea. Other proposals for stretching the critical care workforce include using telemedicine (e-ICUs, staffed by tele-intensivists), expanding the use of nonphysician providers in ICU provider teams, and creating critical care transfer networks, similar to what happens now in trauma care. Very sick patients could be automatically transferred to hospitals with intensivist-staffed ICUs, while less sick ones could go to lower-acuity ICUs staffed by non-intensivists, including hospitalists.

All of these alternative solutions are “more reasonable” than creating a separate pathway for hospitalists that may not adequately train them, says Michael H. Baumann, MD, president-designate of the American College of Chest Physicians and a professor of pulmonary and critical care medicine at the University of Mississippi Medical Center in Jackson. Dr. Baumann is the lead author of an editorial published jointly this summer in the July issues of Chest and the American Journal of Critical Care that criticized the SHM/SCCM fast-track proposal.

The editorial stated the position of the American College of Chest Physicians and the American Association of Critical-Care Nurses: “One year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine.” As the article commented, “such a hospitalist ‘rose’ may be most remembered for its thorns.”

According to Dr. Baumann, while cutting the training time in half may potentially “crank out manpower,” there’s no evidence that it would produce a pool of competent intensivists. “We need to take a deeper dive to look at what are those competencies that a critical care physician should be able to demonstrate at the end of a training program,” he says.

Quality experts have zeroed in on critical care as an area that needs attention. According to The Leapfrog Group, a national patient safety consortium of large health care purchasers, evidence suggests that quality in ICUs varies widely across hospitals.

The group holds that staffing ICUs with critical care-trained intensivists reduces the risk of patients dying in the ICU by 40%. In 2007, the group also estimated that only 30% of hospitals had ICUs that were truly managed or comanaged by intensivists who are either present in the ICU, available by telemedicine or able to respond to pages within five minutes.

One lesson that Dr. Siegal says he learned during his two-year fellowship was that, as a hospitalist, he wasn’t as good at taking care of critically ill patients as he had thought. “It was somewhat eye-opening because I liked to think that I was interested in critical care and that I was pretty good at it,” he says.

Dr. Siegal believes there is “a knowledge base and a skill set” that hospitalists working in ICUs would be well-served to learn. Making that training more accessible to more hospitalists can only help, he notes.

But Franklin A. Michota, MD, director of academic affairs in the hospital medicine department at the Cleveland Clinic, is one hospitalist who remains unconvinced.

“If you are going to hold it out that doctors are equivalent, you have to do the equivalent training,” Dr. Michota says. “Let’s not fool the public that hospitalists can undergo a shortened pathway and be equivalent to critical care doctors who did the longer, standard training. You can’t call them the same thing because the training is not the same.”

Along with other critics of a fast-track pathway, Dr. Michota fears that hospitalists who undergo only a one-year fellowship will always be looked at “and perhaps, more importantly, operate as “”intensivists-lite.”

A heterogeneous workforce
Professionalism, Dr. Michota adds, demands that “if hospitalists are going to work in the ICU, then they need to get themselves trained to work there. Otherwise, you need to let your hospital and your patients know that you are stop-gap and they would really be better off going to another hospital where they can be taken care of by someone with qualifications.”

In many ways, Dr. Michota says, the debate shines a spotlight on a major problem facing hospital medicine: the heterogeneity of the workforce. Hospitalist skills and knowledge vary widely, and the way internal medicine residency programs are now structured makes the problem worse. General internists used to finish residency much more skilled in taking care of inpatients than outpatients. But now, the curriculum puts more emphasis on primary care.

In addition, Dr. Baumann points out, internal medicine residents are required to learn only two procedures: collecting venous or arterial blood samples and placing a peripheral venous catheter. ICU work, on the other hand, requires competence in many procedures, as well as cognitive skills that aren’t covered in internal medicine.

“Critical care has made leaps and bounds in both technical and cognitive issues over the last five to 10 years,” Dr. Baumann says. “People are concerned that many trainees can’t truly obtain all the competencies they need in critical care in one year.”

A nonacademic curriculum
Mary Jo Gorman, MD, MBA, is a critical care physician who now runs tele-intensivist programs in 25 hospitals around the country, working with both intensivists and hospitalists. Dr. Gorman is CEO of Advanced ICU Care based in St. Louis, Mo., and is a co-author of the SHM/SCCM proposal.

She believes a one-year fellowship track for experienced hospitalists is realistic. For one, she notes, there’s the precedent of internists who have done a medicine subspecialty to be eligible for critical care certification they are being after only one additional year of training. “There are well-documented curricula,” she says.

And given the ICU manpower crisis, which will only get worse as the population continues to age, “we need to attack this in every way we can,” Dr. Gorman says. She doesn’t think that “we are going to end up with people who are only able to practice at a significantly lower level” than those trained the traditional way.

“The two-year program is really the academic model; they have research time,” she explains. “If you squeeze that out, put fellows in the ICU all the time and they already have other experience being in the ICU, I think it’s going to be sufficient. They aren’t going to become researchers at the Mayo Clinic, but that’s not what they are being trained for.”

Dr. Baumann notes that the debate raised by the SHM/SCCM proposal has prompted several critical care associations to come together and “determine an evidence-based approach to defining what are the competencies for someone to practice critical care.” The Critical Care Societies Collaborative discussion “just in its initial stages “”is the first stop to get away from time-based training to competency-based training based on outcomes,” he says. He credits hospitalists for giving critical care societies a nudge to begin tackling the much-needed analysis.

“The whole point of this paper was not to start a war, but to start a discussion,” says Dr. Siegal. “Hospitalists are doing this work anyway. We can either recognize that they are doing it and figure out a way to make them better, or we can pretend that the problem doesn’t exist.”

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.