ANESTHESIOLOGISTS IN CRITICAL CARE MEDICINE
Although critical care medicine was originated by anesthesiologists,
they represent a shrinking percentage of critical care physicians. Anesthesiologists
are particularly well trained to manage critically ill patients and do so on a regular
basis in the operating room. A number of factors, however, have led to diminishing
numbers of anesthesiologists practicing in the ICU. This trend comes at a time when
there is an increasing need for intensivists.
The Committee on Manpower for Pulmonary and Critical Care Societies
(COMPACCS) was commissioned by the American Thoracic Society, American College of
Chest Physicians, and the Society of Critical Care Medicine to determine current
patterns of care of critically ill patients. More specifically, the committee examined
the current and projected demand for critical care services and the supply of physicians
based on current supply and training. The COMPACCS survey, performed between 1996
and 1999, found that anesthesiologists comprised 6.1% of all intensivists in the
workforce.[2]
The survey identified that intensivists
provided care to 37% of all ICU patients in 1997.[2]
The demand for intensivists is expected to increase, eventually yielding a shortfall
in intensivist coverage, with supply equal to 35% of demand by the year 2030. Table
74-1
describes the contribution of various specialties in providing critical
care services.
The reason for decreasing representation of anesthesiologists
in critical care is multifactorial. Reimbursement for
TABLE 74-1 -- Characteristics of the critical care and pulmonary specialist workforce
|
Characteristic |
Pulmonary
*
|
Internal Medicine
†
|
Anesthesiology |
Surgery |
All |
|
Total number (%) |
8080 (78.9) |
1220 (11.9) |
620 (6.1) |
324 (3.2) |
10244 |
|
Mean age (years) |
48.9 |
42.1 |
44.8 |
43.3 |
47.7 |
|
Number of women (%) |
727 (9.0) |
144 (11.8) |
61 (9.8) |
45 (13.8) |
977 (9.5) |
|
Base specialty certification (%) |
86.1 |
91.6 |
99.2 |
94.9 |
87.8 |
|
Critical care certification (%) |
50.2 |
65.6 |
59.9 |
80.5 |
53.2 |
|
Type of practice group (%) |
|
|
|
|
|
|
University affiliated |
13.4 |
13.9 |
35.4 |
46.0 |
15.7 |
|
Private solo or single specialty |
50.8 |
47.6 |
50.0 |
31.7 |
49.9 |
|
Private multispecialty |
21.7 |
26.0 |
6.2 |
3.7 |
20.8 |
|
Hospital or health maintenance organization |
9.4 |
5.4 |
8.0 |
11.5 |
9.0 |
|
Other
‡
|
4.6 |
7.2 |
0.4 |
6.0 |
4.7 |
|
Adapted from Angus DC, Kelley MA, Schmitz RJ, et al:
Caring for the critically ill patient. Current and projected workforce requirements
for care of the critically ill and patients with pulmonary disease: Can we meet
the requirements of an aging population? JAMA 284:2762–2770, 2000. |
*Includes
physicians whose only specialty practice was pulmonary medicine and physicians who
practiced both pulmonary and critical care medicine.
†Includes
internal medicine physicians who practice critical care but do not practice pulmonary
medicine.
‡Includes
Veterans Affairs staff.
critical care services is generally less than that for surgical anesthesia services.
Subspecialty training in critical care medicine for anesthesiologists creates a
peculiar situation in which subspecialty training results in lower compensation.
In Europe, most critical care services are provided by anesthesiologists.[3]
The American Board of Anesthesiology and American Society of Anesthesiologists (ASA)
have begun to address the diminishing role of anesthesiologists in critical care
medicine. Possible changes include an increasing component of critical care medicine
training during anesthesia residency.
Structure of Intensive Care Units
ICUs are typically described by their patient population (i.e.,
medical or surgical), and they are now described by their staffing structure (i.e.,
open or closed). Most ICUs in the United States are classified as open, meaning
that a variety of physicians admit patients to the ICU, where they are cared for
by their primary physician, with or without the assistance of a critical care specialist.
The increasing complexity of caring for critically ill patients, however, has led
to recognition of the need for dedicated critical care specialists.
The COMPACCS survey characterized ICUs in four ways:
- ICUs with full-time intensivists, where all or most care is delivered by
the intensivist, in a role greater than that of a consultant
- The consultant intensivist model, whereby an intensivist serves as consultant
but does not have primary responsibility for the patients
- ICUs with multiple consultants, wherein multiple consultants serve the
patient (e.g., a pulmonologist may provide ventilator management), but no one physician
is identified as an intensivist consultant
- The single-physician model, in which the primary physician provides all
the care in the ICU without consultation from an intensivist or other consultants
ICUs in larger hospitals tend to have full-time intensivists,
with smaller community hospitals more likely to use the single-physician model.[4]
The reasons for this tend to be economic, because smaller ICUs may not have adequate
patient volume to support a full-time intensivist. What is the evidence that a particular
ICU structure improves patient outcomes? Many studies are small, retrospective reviews
of the impact of the addition of an intensivist to an existing ICU. For example,
Carson and colleagues[4]
performed a prospective
cohort study of a single ICU that made the transition from the open to closed format.
They found that risk-adjusted mortality scores decreased in the closed ICU despite
higher severity of illness and without additional resource use. Ghorra and coworkers
[5]
showed in a retrospective review comparing two
time periods that mortality and complications were decreased when their open surgical
ICU was converted to a closed model. These two studies suggest that there may be
an advantage to a closed ICU structure, but a truly randomized, prospective study
comparing open with closed ICUs has never been completed.
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