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Eric Chandler, PhD
Manager of Professional Affairs
Society of Critical Care Medicine
Pat Langford
Membership Marketing & Foundation Manager
Society of Critical Care Medicine
Are There More Critical Care Physicians Today?
The healthcare industry is facing a significant workforce issue as many hospitals in the United States and throughout the world deal with shortages of nurses, pharmacists, respiratory therapists and certain types of physicians. In this issue of Critical Connections, we attempt to ascertain if there is a “supply” problem among critical care physicians. Evidence from the Accreditation Council for Graduate Medical Education (ACGME) suggests that while there is a shortage, the number of critical care fellows is increasing and not decreasing as commonly thought.
Despite any increase in intensivist fellows, the shortage will not improve with the current rate of growth. In addition, the increased demand for critical care services reinforces the existing shortage. Even today, only one of every three intensive care units (ICUs) has an intensivist. The aging U.S. population, as predicted in Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) and in other recent reports, promises to increase demand, especially in regions of the United States that attract retirees.1,2
The Society of Critical Care Medicine (SCCM) first addressed this subject in the December 2003 issue of Critical Connections in an article titled “Will They Follow in Your Footsteps?” We looked broadly across nursing, pharmacy and physician categories. Members have expressed concern over the dwindling numbers of physicians in critical care training programs and the exodus of providers from the field, and the Society has attempted to determine the accuracy of these reports. As the U.S. Department of Health and Human Services’ Health Resources and Service Administration (HRSA) prepares to release a report on the supply of critical care physicians, the Society strives to ensure that issues related to a shortage are portrayed accurately and that practical, productive solutions are developed. Using ACGME’s statistics, we examined how many critical care physicians are entering the workforce. Data from other sources may offer different ways of interpreting the state of the workforce, and the Society is dedicated to researching all information related to this important issue.
Is There a Shortage?
Judging by the number of physicians receiving special certification in critical care medicine (CCM), it appears that supply may be slightly stronger than the common perception. Data show that supply has not declined. This stronger showing does not necessarily indicate that the supply is sufficient to meet the demand, and it is important to note that demand may still be outpacing the supply.
According to an annual survey conducted by the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC), the 2004/05 academic year had the greatest number of physicians-in-training (101,291) in allopathic programs ever recorded by the survey.3 Further, growth over the last five years has not occurred in primary care or specialty programs. The growth has been attributed to an increase in fellows training in subspecialty programs such as internal medicine and pediatrics programs accredited by the ACGME.
Does this subspecialty growth indicate an increase in critical care specialists? The number of fellows in critical care subspecialty programs increased by 5.2% from 2003/04 to 2004/05, while the number of fellows in specialty programs increased by only 0.7%. Accordingly, the number of trainees in critical care physician fellowship programs has grown slightly but steadily throughout the past few years. According to the ACGME, an additional 3.1% (54 positions) were filled for the 2005/06 academic year. When compared with the previous year, that amounts to an increase of 14.9% between 2001/02 and 2005/06 (see Figure 1).
Review the Numbers
The data from the ACGME show an overall increase in critical care trainees; three of the four subspecialties show more trainees now than in the past several years. Combined internal medicine pulmonary/CCM continues to be the largest subspecialty training pathway for critical care physicians. Trainees increased by 2.3% (25 positions) in the past year, with an overall increase of 10.7% between 2001/02 and 2005/06.
• Trainees in critical care medicine (internal medicine) decreased slightly by 1.9% (3 positions) in 2004/05 to 2005/06, but increased 13.5% between 2001/02 and 2005/06.
• Trainees in anesthesiology critical care subspecialty programs increased by 24.5% (12 positions) in 2004/05 to 2005/06, recovering from a decline the previous year. These trainees increased 22.2% between 2001/02 and 2005/06.
• Pediatric critical care trainees increased by 3.1% (9 positions) from 2004/05 to 2005/06, with an overall increase of 17.8% between 2001/02 and 2005/06.
• Trainees in surgical critical care increased by 8.4% (10 positions) from 2004/05 to 2005/06, but increased by 38.7% between 2001/02 and 2005/06.
When comparing the number of positions available with the number of filled slots, it appears that program directors have been able to fill approximately 90% of positions over the past several years. About 97% of internal medicine combined pulmonary/CCM slots have been filled, whereas only about 50% of anesthesiology slots have been filled (see Figure 2).
In 2004/05, 29.5% of all critical care trainees were women, the majority of whom were in pulmonary/CCM training programs. The number of women in critical care training programs increased by 4.3% between 2000/01 and 2004/05.
In 2004/05, 36.1% of all critical care trainees were international (foreign) medical graduates (IMGs). The total number of IMGs decreased by 3.3% between 2000/01 and 2004/05.
Information from the AMA’s Fellowship and Residency Electronic Interactive Database (FREIDA) reveals that 641 residents/fellows completed subspecialty training in CCM in 2004, with program directors reporting on 502 (78%) of the graduates (see Table 1).
Table 1: 2004 Graduates' Career Plan Statistics of Critical Care Fellows
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Completing Training |
641 |
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Pursuing more training |
15.3% |
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Practicing in the U.S.** |
39.8% |
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Academic |
38.8% |
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Military |
2.4% |
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Non-medical Career/Left Country |
2.0% |
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Unemployed |
1.6% |
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Total With Known Plans |
502 |
According to program directors, an average of 40% of graduates planned to take up regular community-based practices in the United States, with the remainder choosing academic careers/practice, additional training, military service or other options. For those who graduated from internal medicine pulmonary/CCM programs, 59% were pursuing regular community-based practice compared with 10% of the surgical graduates. Pediatric graduates (62%) were most likely to pursue careers in an academic setting in contrast to 25% of internal medicine pulmonary/CCM graduates. The most graduates pursuing additional training came from internal medicine/CCM training (29%) programs, and the fewest graduates (10%) were from pediatric and internal medicine/combined pulmonary and CCM programs. Only 6% of all graduates were unemployed, pursuing military or non-medical careers, or had left the country.
The Perception of Lifestyle
These figures are encouraging; the number of physicians entering critical care is growing, not shrinking. But they also raise important questions. Why is there a widespread perception that the number of intensivists entering the workforce is shrinking? Why do so many believe that the shortage is caused by a declining interest in practicing critical care?
To answer these questions, the Society surveyed all known critical care fellowship programs in Fall 2005, seeking to understand enrollment trends and identify the aspects of critical care training in need of revision. The Society’s staff, in collaboration with the American College of Chest Physicians (ACCP), polled all critical care program directors listed by the ACGME. Results were broken down by program type: anesthesia, surgical, pediatric critical care, and the internal medicine subspecialties of CCM and combined pulmonary/CCM. Each director was asked if, with sufficient funding, they could add slots and how many, and what would make training more attractive. Most respondents identified pay and hours as their long-term issues. As far as tactics to make training more attractive, some said finding scholarships or other ways to assist fellows with their educational debt would help.
However, most fellowship directors did not point to training as a major area in need of reform. Instead, they said most considering critical care were turned off by the “lifestyle.” Adult and pediatric medical directors said medical graduates increasingly aim for a predictable workweek and value time outside of the hospital or clinic. They lean toward radiology, for example, and avoid family practice or other positions associated with longer hours.
Not only does the number of physicians evoke concern, so does the work effort put forth by physicians in practice. According to the Baltimore Sun, male and female physicians want to practice fewer hours.5 Richard Cooper, MD, a recognized healthcare workforce policy expert, reports that women practice on average 20% to 25% less than their male counterparts because they bear a disproportionate share of family responsibilities.6 By 2020, women are expected to account for 60% of medical students and 45% of practicing physicians in the United States. If Cooper’s data apply, this mix of male and female practitioners would suggest a reduction in the amount of care delivered without any reduction in head count.
Critical care program directors suggested a transition similar to the one that occurred in pediatric emergency medicine. They proposed shifting schedules to allow physicians to contribute without sacrificing family time. Those polled were aware of the catch-22 relationship between lifestyle and the workforce shortage. A shortage of intensivists contributes to a less attractive lifestyle, but there is little opportunity to improve this situation without an increase in available intensivists. It’s difficult to expect an influx when sacrifices in lifestyle and burnout are considered standard expectations.
However, there is hope. Several directors noted that the lifestyle often is depicted as worse than it is. Many candidates are exposed only to “the hard part” of critical care without being told of the rewards. By exposing medical students and residents to the positive aspects of critical care, including the strong bond developed with patients and their families and changing recruiting and training practices, the critical care field could attract more candidates who prematurely reject it as an option.
The Future of Critical Care
The workforce shortage is a very real problem for all members of the expert team, including physicians. The demand for critical care services will increase with the aging population, and advances in medicine are increasing patients’ expectations. Long-standing shortages of nurses, clinical pharmacists and respiratory therapists add to this challenge. Although there are more critical care physician trainees in the United States today, there are not enough to meet projected demands or to provide an intensivist for every ICU in the country.
Despite the ACGME figures indicating that interest is strong for critical care, there are at least three qualifications to this data. First, these data do not address the number of team members leaving the profession. While new physicians entering critical care fellowships may be growing, it is possible that practicing intensivists are leaving at a higher rate. Data from the Society’s 2004 compensation survey indicate that 80% of respondents planned to continue in critical care until retirement, with an average retirement age of 62. However, data do not indicate whether those respondents will reduce their patient load before retirement; they only indicate that respondents will continue to see critical care patients. Those who anticipate shifting their focus said they plan to do so at age 52, indicating 10 years of practice devoted to non-critical care.
Second, data indicate that though more than 90% of critical care fellowship slots are filled, many fellowship directors say they would have difficulty filling additional slots if they were available. Current slots are nearly full, yet directors seem to think this does not indicate a demand for more fellowship slots. They interpret the nearly-full programs as a sign that they are the “right size,” although they agree that we do not have enough intensivists. Additional research is needed to find why this discrepancy exists and if changes in these subspecialty practices are needed to make them more attractive to fellows.
Third, data from the American Board of Surgery (ABS) raises some questions, and data from other specialty boards and other sources still must be analyzed. The number of certifying examinations provided by the ABS increased 18% between 2001 and 2005, but dropped dramatically (9%) in the last year (2004 to 2005). The number of recertifying examinations declined 39% between 2001 and 2005. An overall trend is not clear, given the reversal in 2004 and 2005.
Findings from ACGME data do establish an important point. The widespread perception that interest in critical care is declining paints a bleaker picture than warranted. A shortage of clinicians does exist and further research is needed to gain the full picture of how this shortage may affect the future of healthcare, but it is crucial to know the facts and focus our efforts in the appropriate areas. Together, we can ensure that all critically ill and injured patients get the quality of care they deserve and all providers have the appropriate support when delivering that care.
Figure 1: Critical Care Physician Fellowships Filled
Figure 2: Positions Filled and % Unfilled Positions
Sources: ACGME number of accredited programs and filled positions by specialty by academic year. (online http://www.acgme.org/adspublic/) and US Graduate Medical Education, 2004-2005, JAMA, Sept 7, 2005 pp 1075-1082), Appendix II, Table 10
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