Will They Follow in Your Footsteps?

David Julian Martin, CAE

My Aunt Rose, when updating out-of-town family on what friends’ and neighbors’ children were doing, said things like, “Michael had a calling for medical school.” Doctors, nurses, priests, and fireman, it seems, all had “a calling.” What she meant, I believe, was that they had a desire to enter a particular vocation. Those with a “calling” certainly do not enter a field of study simply to get a job. A calling or vocation means that you enter a profession because you have an internal drive to fulfill the activity for the greater good. And that is why professionals tend to enter into a particular area. It gives them superior technical authority as well as moral authority.(1) As critical care professionals, you have answered your calling.

Healthcare is among the vocations only possible through altruism. It often requires the self-sacrifice of one’s own life. As many SCCM members have recently commented, critical care professionals aren’t getting younger. The concern is whether enough new, young recruits have the calling and are ready to follow in your footsteps.

I recently spoke to two SCCM members who have children that will soon enter college. The households consist of parents who are both in healthcare and are passionate for improving patient care. If anyone’s children had “a calling,” I thought it would be their children. Surely they would want to follow in the footsteps of their parents. I found, however, that none of the five children in question seem to be considering healthcare as a profession. When I asked why, I was told they see how long and hard their parents work and they want a better lifestyle.

As we all know, a shortage of pharmacists, respiratory care therapists, and critical care nurses already exists. A shortfall of critical care physician specialists (intensivists) has been projected within the next 10 years and by some accounts may already be upon us.(2) Today, intensivist directed multidisciplinary teams care for only one out of every three patients in ICUs in the United States. Will we be able to boost this already less-than-ideal number of healthcare specialists and deal with the increased demand an aging population will require?

Nurses
According to a report from the U.S. Department of Health and Human Services, an increase in the demand for care coupled with the nursing shortage is already evident and is projected to grow from a shortage of 6% in 2000 to a shortage of 29% by 2020.(3) Factors contributing to the nursing shortage include “the declining number of nursing school graduates, the aging of the RN workforce, declines in relative earnings, and the emergence of alternative job opportunities,”(3) states the report.

Furthermore, the American Association of Critical Care Nurses (AACN) indicates that currently the most significant shortages are in “areas which require experienced nurses with highly specialized skills.”(4) Dorrie Fontaine, RN, DNSc, president of AACN, explains, “There is a public health crisis called the nursing shortage in this country with critical care areas as one of the hardest hit specialties.”

However, critical care nursing may have a more positive future due to peaked interest in the specialty track. “For critical care nursing, the outlook is good for three reasons: nurses in critical care are part of an active team; the staffing is often better – it is fast-paced and the staffing ratio is often 2:1 or 1:1; and critical care attracts people who want to be active in what they do and want to expand beyond basic nursing care,” adds SCCM Member Charold L. Baer, CCRN, PhD, FCCM, professor in the School of Nursing at Oregon Health & Science University.

Pharmacists
Critical care pharmacy is encountering more difficult challenges, however. According to research cited in a 2000 report by the U.S. Department of Health and Human Services, The Pharmacist Workforce: A Study of the Supply and Demand for Pharmacists, the number of available pharmacists is expected to decrease during 2000 to 2010 by 0.2% compared to the previous decade, thus not keeping pace with population growth and the subsequent increased demand.(5) Furthermore, the number of pharmacy graduates is expected to remain the same from 2000 to 2005, figures that stifle hope for improving the current workforce shortage.

The number of pharmacy graduates entering critical care residencies remains low, compared to other types of residencies. While pharmacy practice (591) and primary care (98) residencies were the most available types in 1999, critical care only had 19 pharmacists complete critical care residencies in 1999, a figure that is much in line with other subspecialties, including psychiatric, geriatric, pediatric and oncology.(5) Steven J. Martin, PharmD, FCCM, an SCCM member and associate professor at the University of Toledo College of Pharmacy, affirms that there appears to be an insufficient number of pharmacists in critical care medicine.

“First, it is hard to convince pharmacists to complete two to four years of postgraduate work, such as advanced residency training or fellowship in critical care, when they can do fairly well in terms of salaries without this extra training,” says Dr. Martin. “In addition, pharmaceutical companies are quickly hiring these well-trained pharmacists before they have a chance to enter the patient-care workforce. It is difficult for institutions to find well-trained critical care pharmacists. Many positions go unfilled for long enough that the institutions decide to leave them unfilled.”

Dr. Martin suggests that the number of advanced pharmacy residencies in critical care may decrease over the next few years because of the Centers for Medicare and Medicaid Services’ (CMS) recent decision to no longer reimburse programs for specialty pharmacy residencies, including critical care. And while institutions’ pharmacy department budgets appear to be increasing to accommodate the increased need for pharmacists, Dr. Martin notes that this increase is largely due to the increase in drug costs, and not an increase in pharmacy staff. “It will be hard to continue to expand the multidisciplinary team approach beyond its present level without enough pharmacists,” he concludes.

Physicians
Critical care physician fellowship programs appear to be stable or growing slightly. According to the Accreditation Council for Graduate Medical Education (ACGME), an additional 66 positions were filled across all program types in critical care medicine from July 1, 2002 through June 30, 2003, a 4.3% increase, compared to the previous year, which witnessed only a minor shift of 0.8%.(6) While the number of critical care fellows entering anesthesiology took a hard hit from 2001 to 2002 (a decline of 18%), surgery and pediatric subspecialties appear to be stable, with only minor influxes over the past three years. In addition, the largest subspecialty in critical care continued to be those in pulmonary medicine programs.

An American Board of Internal Medicine (ABIM) analysis of first-year fellows (F1s) in individual programs indicated stable or slight increases in numbers of F1s over the prior eight-year period, with declines between the 1994/95 and 1997/98 academic years.(7) However, the number of pulmonary/critical care medicine F1s returned to approximately 500 for the 2001/02 academic year. The gender mix also remained relatively unchanged in that group. Other subspecialties within internal medicine saw similar activity with only geriatric medicine experiencing a steady increase.

These findings indicate that while industry sentiment may suggest a current shortage of physicians entering the field of critical care, the perceived “shortage” may not have merit. In fact, an American Medical Association (AMA) survey shows that critical care fellowship programs could accommodate an increased number of positions.(8)

According to the survey, the number of future positions that program directors indicated they would have from 2003 to 2004 is approximately 15% higher than the ACGME’s account of filled positions in 2002 to 2003.

But with an aging population and more ICUs converting to the intensivist-directed model of care, will this meager increase in numbers be sufficient to keep up with demand? If not, how might we stretch our current level of resources to ensure high quality critical care?

Can We Meet the Demand?
In many professions today, it’s tough to find a job. But not of course, in healthcare. We have a shortage after all. But could outsourcing certain healthcare functions offset our potential future supply problems?

Technology has allowed companies to handle rising sales without adding manpower. Gains in productivity mean that one white-collar worker can complete the work that would have taken two or three of his peers to complete 10 years ago. For example, consider the cost and shortage of certified radiologists to interpret film. A company located in one of India’s high-tech cities is now providing this service over the Internet. They have discovered that physicians can be outsourced overseas too. Patients in America and Europe are receiving services from an office park in Bangalore, India, not far from where Ernst & Young has 200 accountants processing U.S. tax returns.(9)

In addition, electronic ICUs are gaining in popularity. Electronic ICUs combine telemedicine and computer software applications and enable off-site critical care practitioners to monitor and provide care with the help of on-site staff, to ICU patients 24 hours a day, seven days a week. Electronic ICUs have been shown to increase patient surveillance, improve error trapping and facilitate preemptive care.

Virginia-based Sentara Healthcare has been using the eICU, developed by VISICU, Inc., for more than two years. Since Sentara implemented its eICU, the healthcare organization has experienced a 27% decrease in severity adjusted hospital mortality for ICU patients and a 17% decrease in ICU length of stay.(10) And like having an intensivist on site, this “remote intensivist” program can generate substantial financial benefits due to the decreased care costs and improved patient throughput in the ICU.

Taking Action
As the only organization representing all facets of the critical care team, SCCM is working on a number of fronts to address the workforce shortage. The SCCM Advocacy Committee is collaborating with Senator Jeff Bingaman (D-N.M.) who introduced new legislation (S.1498) designed to establish a Health Workforce Advisory Commission that will review federal health workforce policies and make appropriate recommendations. In addition, SCCM has partnered with other organizations to develop a white paper entitled, “The Critical Care Medicine Crisis: A Call For Federal Action.” This important document was sent to the Health Resources and Service Administration as a follow-up to meetings held with the agency to discuss the growing problem. Specific action plans are being implemented to address the recommendations included in the paper such as:

• Improving the efficiency of critical care providers by supporting research and demonstration projects on optimal systems for delivering critical care, standardizing information platforms and researching the viability of regionalizing critical care resources.
• Increasing the number of providers by taking steps such as expanding the J1 visa waiver, providing full graduate medical education payment for residents and fellows, increasing caps on training positions, expanding loan forgiveness, and increasing funding for federal health professional training programs.
• Addressing the patient demand issue by supporting research that provides services to the elderly and conducting an educational campaign to educate the public on both the benefits and limitations of critical care.
  
• Furthermore, SCCM in partnership with the American Thoracic Society and the American College of Chest Physicians will introduce a motion in the AMA House of Delegates to formally recognize these shortages.

The Society is also working to educate medical students about critical care and is planning to update and distribute its “Medical Students Guide to the ICU,” which can be found on the SCCM Web site at www.sccm.org/publications/index.asp. In addition, last year the Society awarded a complimentary trip to the Critical Care Congress to the winner of it’s Medical Student Essay Writing Contest.

These efforts represent only a margin of the Society’s many activities to ensure a sufficient supply of critical care professionals exists to care for future patients. Through our efforts, and with your help, we hope to instill in more young healthcare workers the “calling” to specialize in critical care.