Stephen Weston finds everything about the intensive care unit exciting: the life-and-death decisions, the teamwork between specialists, and the head-scratching that goes into treating complex cases. A second-year medical student at the University of California-San Diego, he was introduced to hospital work when he had a job as a respiratory therapist. Now he's found a specialty that will put him squarely in the ICU: critical care medicine.
Physicians with specialized training in critical care, known as intensivists, treat some of the most seriously ill patients in the hospital—those on ventilators or dialysis and those with multiple organ failure. After med school, Weston plans to do a residency in anesthesiology followed by a yearlong fellowship in critical care medicine.
Ever since critical care was recognized as a specialty in the 1980s, hospitals, physicians, and patients have been reaping its benefits. Studies have shown that full-time intensivists, devoted solely to critically ill ICU patients, can trim the length of hospital stays, reduce medical errors, and improve mortality. According to Robb Glenny, a pulmonary critical care specialist at the University of Washington: "That's a win-win situation all around—reducing costs for hospitals and benefiting the patients' survival."
Indeed, the insurance industry has taken notice. The Leapfrog Group, a consortium of large businesses and organizations that includes GE and IBM and promotes healthcare quality and safety, supports the widespread adoption of intensivist-led ICUs. "The intensivist brings an expertise not only to the medical management of acutely ill patients but also [to] the integration of and coordination with other physicians and surgeons," says Peter Pronovost, a professor of anesthesia critical care at Johns Hopkins Medical School and a medical adviser to the Leapfrog Group. The result? A previously "unheard of" 30 percent reduction in mortality, he says.
Single focus. Intensivists have been able to accomplish this by pioneering new standards and protocols in ICU treatment. Specialists point to the dramatic improvement of acute lung illness and injury with advancements in ventilation and lung volume control strategies developed by critical care specialists. Intensivists have more time to devote to ICU patients without the added stress of seeing patients on other floors or off site. This has helped patients with diseases ranging from pulmonary embolism—a blockage of the artery leading from the heart to the lungs—to liver failure and even pneumonia.
With aging baby boomers as its driving force, demand will remain high for more than a decade as hospitals make the switch to intensivist-managed ICUs and as more and more payers insist they have full-time critical care physicians on staff. "Even if we doubled the number of fellowships over the next 10 years, there still wouldn't be enough intensivists to meet the job market's needs," says Gerald Maccioli, president of the American Society of Critical Care Anesthesiologists. If current trends continue, there could be a shortage of intensivists by 2020.
From a lifestyle point of view, part of critical care's appeal, says Derek Angus, chairman of the department of critical care medicine at the University of Pittsburgh, is its reinvention as a shift specialty, much like emergency medicine or trauma surgery, with concrete hours—when you're done, you're done. And with a competitive starting salary of around $187,000—and $215,000 for critical care plus pulmonology—the field is likely to attract even more interest.
Critical care medicine is attractive to physicians from a range of medical backgrounds, a feature many experts believe makes for superior patient care and, ultimately, better outcomes in the ICU. While more than 80 percent of intensivists come from internal medicine, those with residency training in general surgery, anesthesiology, pediatrics, and obstetrics and gynecology, can obtain a fellowship or certification in critical care medicine.
Taking charge. Although the ICU is hardly the boardroom, critical care training programs focus increasingly on developing managerial skills. "Intensivists need to be leaders during medical crises, managing a whole cadre of nurses, pharmacists, and respiratory therapists," says Angus. Beyond the medical staff, the intensivist must coordinate with social workers and case managers to help patients' families. "When patients are that sick, it's not only a crisis of the body but a crisis of the family. And intensivists are able to develop deep bonds with them in a relatively short period of time," notes Stephen Frankel, section head of critical care and hospital medicine at National Jewish Medical and Research Center in Denver.
Pittsburgh's program, one of the first and, with about 40 fellows, one of the largest in the country, now runs simulations in a multilevel facility using actors and "robotic" humans. There, future intensivists practice crisis management and learn how to lead an entire ICU team. In one scenario, an actor playing a patient diagnosed with an aggressive cancer becomes unstable, with multiple organ failure. And just as NFL teams review tape to improve performance, "we use video to evaluate how the fellows perform in an end-of-life situation," says Angus.
The football analogy doesn't stop there. Being an intensivist means keeping a lot of people in the loop, says Frankel. "Some liken it to being the captain of a ship, but I think it's more like being a quarterback."