DETROIT—Remember the prognostication in the 1990s about an impending glut of specialists? Not true, said Mark A. Kelley, MD, at least not in pulmonary and critical care medicine. Instead, the United States may well face a shortage of these specialists in less than a decade, he reported.

Dr. Kelley based his prediction on a three-year study that assessed current and future needs for pulmonary and critical care medicine in the United States.[1] The study was performed by the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS), which comprised representatives from the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine.

Dr. Kelley, Chief Medical Officer and Executive Vice President at the Henry Ford Health Systems in Detroit, was committee chair.

THE GRAYING OF THE BABY BOOMERS

According to the report, the advancing age of the baby-boomer generation is creating a disease burden that will cause the demand for pulmonary and critical care services to outstrip the supply of specialists in those fields.

“As people age, they tend to have more chronic diseases and are more likely to end up in the intensive care unit (ICU),” Dr. Kelley reported in an interview with PULMONARY REVIEWS.

To formulate their predictions, the committee used national population, hospital, patient, and clinician data derived from multiple sources. Details of the study methodology are given in the box found below.

PHYSICIANS ALREADY ARE HARD AT WORK

The study found that pulmonary and critical care physicians are already working hard. On average, they currently work about 61 hours a week for 48 weeks per year, or 2,933 hours annually. Of that time, 2,284 hours are spent in clinical activities.

In 1997 (the most recent year for which figures are available), intensivists cared for 36.8% of all ICU patients, the study revealed.

Intensivist-provided critical care was most common in regions of high–managed care penetration, which surprised the study authors in light of managed care’s reputation for limiting the use of specialists. Table 1 reveals the age distribution among patients who were receiving treatment in ICUs at the time of the survey.

In 1997, the estimated number of outpatient visits to pulmonary specialists in the United States topped 6.8 million. However, only 2.7% of all outpatient visits for respiratory diagnoses were made to pulmonologists. Table 2 provides a representative sampling of diagnoses and the number of office visits to pulmonologists per 1,000 person-years for 1997.

The supply and demand for intensivists will remain essentially unchanged until 2007, the authors forecasted. The demand will then rapidly increase, but the supply will remain about the same, producing a shortfall of 22% by 2020 and 35% by 2030.

PULMONOLOGISTS WILL BE LOST MOSTLY TO ATTRITION

The study found a similar pattern for pulmonologists, although a shortage in their services is likely to occur before 2007 because retirees from pulmonary medicine are expected to outnumber new graduates. This shortage will be even more severe than the one predicted for intensivists, reaching 35% by 2020 and 46% by 2030, according to the authors’ projections.

THE RESULTS ARE A WAKE-UP CALL

In the sensitivity analysis, aging of the population was by far the greatest influence on both types of physician shortages. Health care reform and modification of existing practice patterns may only temporarily forestall the problem, the analysis suggested.

If the study’s predictions are accurate, the result may be increasingly inadequate pulmonary and critical care services, leading to greater morbidity and mortality. “This is a wake-up call to policymakers that we are going to run out of intensivists and pulmonary physicians unless someone starts addressing this problem,” Dr. Kelley emphasized.

The COMPACCS report differed from similar studies in several ways, the authors contend. First, the report’s forecast extended to 2030, well beyond the 2010 time frame used by the other studies, and thereby captured a “major demographic shift toward the elderly” population. Second, the authors rejected the popular wisdom that managed care would decrease demand, an assumption made by other investigators.

COPING WITH THE CRISIS: NOW AND IN THE FUTURE

The COMPACCS report suggests that managed care may actually increase the demand for intensivists. “If there is any criticism of our study, it is that we projected too conservatively and the crisis may already be here,” Dr. Kelley added.

Some experts believe that the crisis is already here. For example, the Leapfrog Group, a consortium of Fortune 500 companies that has been seeking ways to make health care delivery more cost effective, has proposed that hospitals staff nonrural ICUs with physicians who have critical care credentials.

The group estimates that this could prevent many thousands of deaths annually in this country. But the proposal would require an increase in the number of trained intensivists and thus would make the intensivist shortage even greater than that projected in the COMPACCS report.

THINKING OUTSIDE THE LINES REQUIRED

If the crisis is indeed already upon us, hospitals should be employing “out-of-the-box” thinking and making innovative use of available resources, emphasized Thomas Rainey, MD, in an interview with PULMONARY REVIEWS.

“One of the more creative solutions [that] I have seen is remote monitoring of ICUs by trained intensivists,” said Dr. Rainey, former President of the Society for Critical Care Medicine (SCCM) and Chair of the SCCM’s Coalition for Critical Care Excellence. Dr. Rainey is also a member of COMPACCS and Director of Critical Care at Suburban Hospital in Bethesda, Maryland.

Remote monitoring can be accomplished through video cameras and computer links to ICU equipment, allowing patients to be observed off-site continually, Dr. Rainey told PULMONARY REVIEWS. Further, this type of system can markedly decrease ICU mortality by allowing the intensivist to catch problems earlier in their occurrence, Dr. Rainey reported.

--Timothy Begany

Reference
1. Angus DC, Kelley MA, Schmitz RJ, et al. 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. 2000;284:2762-2770.