American Journal of Respiratory and Critical Care Medicine

Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.

In the United States, more than 4 million patients are admitted to an intensive care unit (ICU) each year, ICU-related spending approaches $80 billion annually, and one in five of all deaths occurs in a hospitalization involving the ICU (1, 2). Data such as these have prompted healthcare administrators and policy makers to search for ways to improve the quality and efficiency of critical care (3). Increasing the number of patients receiving care by a trained intensivist physician is one such strategy (4). Most studies suggest that intensivist staffing is associated with lower mortality in the ICU (5). However, only a minority of ICUs in the United States are staffed by trained intensivists (6), creating a workforce gap that is expected to widen as the population ages and the incidence of critical illness rises (7).

Labeled a “crisis” by the major critical care professional societies (8), the workforce gap has led to a number of calls to increase the intensivist supply (9). Suggested strategies include increasing graduate medical education (GME) training slots for intensivists; expanding the J-1 visa waiver program, which would allow physicians from other countries to train as intensivists and practice in the United States; creating economic incentives for physicians to enter the specialty through increased reimbursement and loan repayment; and even developing novel training pathways so that practicing hospitalists can become board-certified intensivists through a shortened fellowship (1012).

We believe that these calls for more intensivists, although well intentioned, are also misguided. In this perspective, we advance the argument that expanding the intensivist supply is not a practical solution to the workforce problem. First, we explore the underlying reasons for the workforce gap in critical care. Second, we discuss why efforts to expand the intensivist workforce will not close this gap and in fact may have unintended harmful consequences for the healthcare system as a whole. Finally, we outline policy alternatives that can meaningfully address the dual problems of deficient quality and excess spending in critical care without an unnecessary expansion of the intensivist supply. Our argument focuses on the U.S. health system because the claims for training for intensivists come primarily from U.S. authors. However, we draw lessons from other developed countries, and the basic principles of workforce planning we espouse apply to all healthcare systems.

The primary reference for the workforce gap in critical care medicine comes from a 1998 analysis sponsored by several critical care professional societies, published in 2000 (7). To measure the workforce supply, the authors surveyed physicians and ICU directors to understand how much of their current practice was devoted to critical care. To measure demand for critical care, the authors used standard workforce forecast models based on age-adjusted per capita ICU use, projecting these rates into the future using estimates for population growth and aging. At the time of the report there was already a workforce gap, because many critically ill patients were not cared for by an intensivist. And because the majority of patients admitted to ICUs are elderly, the gap was projected to worsen as the baby boomers aged. These results were later replicated using similar methods in a report by the U.S. Health Resources and Services Administration (13).

The problem with these conclusions, however, is that they rest on the assumption that all patients currently admitted to an ICU in the United States are in need of critical care. On the contrary, a substantial proportion of ICU patients are of relatively low illness severity. For example, in a large database of 78,222 ICU admissions in 45 hospitals, only 67.3% of patients received any active ICU-related treatment during the course of their stay (14). In another study of 226,942 patients in 97 ICUs only 39.5% of patients were receiving mechanical ventilation at any given time (15). Intensivists who practice in large referral centers frequently encounter ICUs packed with sick patients, but the reality is that many patients are admitted with lower severity of illness to ICUs. This notion is supported by a survey of U.S. critical care clinicians, which showed little evidence of access limitations to the ICU, instead revealing far greater concerns about overuse (16).

In truth, decisions to admit to and discharge from the ICU are supported by a limited evidence base and are influenced by a number of factors, only one of which is patient need (1719). Without a doubt, many ICU patients are indeed critically ill and will benefit from the experience and skill of a trained intensivist. But at present, many others are unlikely to benefit from an intensivist or care in an ICU compared with continued care on a ward. As a consequence, workforce estimates that employ current use of an ICU bed in the United States substantially overestimate demand, inflating the size of the projected gap.

Although we argue that the actual intensivist workforce gap is overstated, based on the analysis of demand, it is still likely that there are critically ill patients in understaffed ICUs who would benefit from intensivist staffing. Yet, there are compelling reasons why efforts to expand the intensivist supply would not help these patients, and may even lead to negative consequences to the health system as a whole (Table 1).

Table 1. Counterarguments to Calls for Increasing the Intensivist Physician Supply

New intensivists are difficult and costly to train in meaningful numbers
New intensivists would not work where they are needed most
New intensivists would not mitigate the shortage of other members of the critical care workforce
Focusing on intensivists unjustifiably prioritizes intensive care over primary care and other subspecialties with physician shortages
We Cannot Easily Increase the Intensivist Supply

The most cited policy proposal for increasing the number of intensivists is to expand the number of GME training slots for fellows in critical care (10). Yet an increase of the magnitude necessary to fill the perceived gap is not feasible or affordable. The U.S. Health Resources and Services Administration report projected a shortfall of 3,330 intensivist full-time equivalents by 2020, or a gap larger than the entire projected supply (13). Even doubling the current number of training slots would not come close to filling that gap. However, increasing the number of training slots would come at great expense. Already the United States spends $15 billion on GME, money that comes directly out of the healthcare budget (20). There is no indication that the U.S. government, which finances the vast majority of GME, is willing to pay for more training slots. On the contrary, existing government proposals actually involve lowering the number of hospital-based training slots (21). Hospitals, which are faced with ever-dwindling revenue, are equally unlikely to pay for this training (22).

Even if we could expand the number of slots, there is no guarantee that there would be high-quality residents to fill them. Because of stress, long hours, and burnout, critical care is not among the popular specialties for internal medicine graduates (23), and comparatively low reimbursement makes critical care relatively unattractive for anesthesia, surgery, and emergency medicine graduates (24). Filling these spots with foreign medical graduates by expanding the J-1 visa waiver program is ethically problematic given concerns about “brain drain” from low-income countries, which need qualified physicians as much as, if not more than, the United States (25).

New Intensivists Will Not Work Where We Need Them to Work

Even if we were able to train a meaningful number of new intensivists, they are unlikely to choose to work in regions with the shortest supply. The majority of new specialists want work in urban and suburban areas (26), whereas hospitals without intensivists are primarily in small towns in rural settings (6). Despite deficient supply in rural areas, referral centers in urban areas continue to recruit intensivists, using them to reduce staffing ratios (27) and staff the ICU at night (28). Creating more intensivists will do nothing to mitigate these regional disparities in access. This pattern reflects trends in medicine as a whole, in which regional disparities in access go unaddressed even as more physicians join the workforce (29).

Physicians Are Only One Part of the Critical Care Workforce

Critical care is inherently interprofessional, and good evidence suggests that a multidisciplinary approach to care is associated with improved critical illness survival (30). Efforts to increase the physician supply will be of little use without concurrent efforts to increase the supply of other critical care professionals including nurses, pharmacists, and respiratory therapists, all of whom are reporting workforce shortages (31). Even with recent increases there is still a projected shortage of 260,000 nurses by 2020 (32). This shortage will have particular implications for critical care, which depends on highly skilled nurses who, like ICU physicians, require time and money to train (33). Because nurses are both the afferent and efferent limbs for the vast majority of ICU management strategies, this shortage could have profound implications for critical care delivery. More intensivists may address the mathematical gap between physician supply and demand but will not improve patient outcomes in the absence of these other care providers.

Other Physician Specialties Face Equal if Not Greater Supply Limitations

An underlying assumption of efforts to increase the intensivist supply is that critical care is somehow unique among physician specialties. Yet in fact, any perceived intensivist shortage must be viewed in the context of a much more significant physician shortage in the United States. According to the Association of American Medical Colleges, 22 medical specialties reported workforce crises over the last decade: not only critical care but also primary care, emergency medicine, general surgery, and oncology, among others (34). There is no compelling reason why intensivists should be prioritized above these other specialties. Although intensivists might argue that they are more important or more lifesaving, these arguments would be challenged if used to prioritize training of intensivists over primary care physicians whose care may help prevent ICU admissions, or oncologists and surgeons who provide care that is arguably just as lifesaving. If anything, given the large population benefits of primary care, a strong case could be made that it is more important to train primary care physicians than specialty physicians such as intensivists (35). Thus efforts to selectively train more intensivists may actually lead to harm to the overall U.S. health system, which is facing a demonstrable shortage of primary care physicians (36).

Perhaps the biggest problem with focusing on the intensivist supply is that it distracts us from the real problem. As others have written about primary care (37), it is best to view the workforce problem not as a physician shortage but as a mismatch of supply and demand. There is simply too much demand for critical care and not enough supply to meet that demand. Framed this way, focusing efforts on increasing the supply of intensivists means that we miss the opportunity to develop innovative strategies for better matching long-term supply and demand. Here we discuss some alternative strategies for addressing workforce issues that do not involve training more intensivists (Table 2). We believe these strategies not only are more likely to align supply and demand but also are more practical and sustainable than increasing the intensivist supply.

Table 2. Alternative Policies for Reducing Supply/Demand Mismatch in Critical Care

Improve Quality of Intensive Care without Relying on Increased Intensivist SupplyReduce Demand through Implicit Rationing
Nonphysician providersLimit ICU bed growth through certificate of need laws, incentivizing safe and effective triage
Telemedicine
Computerized decision/support
Regionalization
Distance-based education and quality improvement

Definition of abbreviation: ICU = intensive care unit.

Improving Quality without More Intensivists

There are numerous ways to potentially improve the quality of critical care with our current supply of intensivists. For example, interprofessional care models driven by nonphysician providers could be used to deliver care for ICU patients with low illness severity (38). Early data indicate that ICUs staffed by nurse practitioners and physician assistants provide care of a quality similar to traditionally staffed ICUs (39, 40). Use of these providers could then free up intensivists to oversee the system and care for the sickest patients.

ICU telemedicine is another potentially underused approach. At present, ICU telemedicine is used mainly for monitoring at night (41, 42), with only small reductions in mortality (43). A complementary approach would use ICU telemedicine not only for nighttime monitoring but also for daily rounds and remote screening for evidence-based practices (44, 45). Although intensivists likely impact outcomes through multiple mechanisms, one of the best defined is through the routine implementation of evidence-based practice (46, 47). The use of telemedicine to aid best-practice implementation, perhaps paired with computerized decision support (48) and distance-based education (49), might allow patients in nonintensivist-staffed ICUs to receive high-quality care without requiring an intensivist at the bedside.

A third approach is through regionalization of care, which can improve quality by concentrating patients in regional centers of excellence (50). High-volume ICUs tend to exhibit lower risk-adjusted outcomes, even after controlling for intensivist staffing (51). Routinely sending the sickest ICU patients to high-quality centers might improve quality. Regionalization could also increase efficiency by creating economies of scale, decreasing per patient costs by spreading the fixed costs of critical care over a larger number of patients (52).

These strategies are not a panacea. Each has its own staffing limitations; for example, it may not be easy to recruit nonphysician providers to work in intensive care settings. And as yet none are supported by a robust evidence base. Indeed, promising new technologies and care models frequently fail to improve healthcare quality and reduce costs (53). Information technology, in particular, may have been oversold as a safe and effective tool to improve quality and reduce costs (54). Robust effectiveness research is needed to determine whether nonphysician providers, telemedicine, and regionalization can truly improve quality in the absence of bedside intensivists.

Decreasing the Demand for ICU Care

While we work on increasing critical care supply without more physicians, it is equally important that we work on reducing demand. The United States consumes far more critical care and spends more of its gross domestic product on healthcare overall than other industrialized countries (55), yet achieves similar outcomes (56). Within the United States there is substantial unexplained variation in the use of ICUs, even controlling for admission diagnosis and severity of illness (57, 58). However, hospitals that tend to use more critical care do not experience improved outcomes (58). Although not definitive, these patterns strongly suggest overuse of critical care, making it essential that we take steps to reduce overall demand.

How might this be accomplished? The conventional answer is through an evidence-based approach that uses explicit criteria to deny ICU admission to patients with little or no chance of benefiting. Unfortunately, we lack sufficient evidence to support explicit criteria, and failed attempts in our field to define “futile” care suggest that an explicit list of contraindications to intensive care is unlikely (59). Even if we could develop explicit criteria for ICU admission, there are significant barriers to their use. It would be unlikely that a single decision rule would work across multiple institutions of varying capability to deliver care in alternative locations. Moreover, cognitive biases such as “rescue” (the motivation to devote any resource to save a life at imminent risk regardless of cost) and “chagrin” (the motivation to avoid poor outcomes associated with passive options toward lower levels of care) would overcome bedside decision rules, so long as ICU beds were available (60, 61). The political barriers to explicit rationing are also significant, as suggested by experiences of the United Kingdom and Oregon (62) as well as the hyperbolic debate over “death panels” in the United States (63).

An alternative strategy to explicit guidelines is implicit rationing. Implicit rationing works by reducing the relative number of ICU beds and then allowing physicians to optimize the use of those beds through individualized triage at the bedside (64). This strategy is likely to be safe for several reasons. Multiple studies suggest that transient limitations in ICU beds lead to more judicious use of the beds, including fewer low-risk admissions, more palliative care outside the ICU, and speedier discharges of recovering patients, without worsening overall outcomes (6568) (Table 3). On the basis of these data, it is likely the United States could make do with substantially fewer ICU beds per capita without significant harm to patients. And because the vast majority of ICU costs are fixed, fewer ICU beds means substantially lower hospital costs, making inpatient care less costly for all patients, not just those admitted to the ICU (69).

Table 3. Examples of Observational Studies and Natural Experiments from North America Indicating That Implicit Rationing through Constrained Supply of Intensive Care Unit Beds Is Likely to Be Safe and Effective

ReferenceHospitalsSummary of ExperimentSummary of Outcomes
Singer et al., 1983 (65)1A nursing shortage leading to a reduction in the medical ICU from 18 beds to between 8 and 14 beds• Monthly admissions decreased from 122 to 95
• Average occupancy increased from 77 to 90%
• Major interventions increased from 33 to 39%
• Patients with chest pain admitted to the ICU decreased from 85 to 63%
• Intubation rate among patients with respiratory distress increased from 34 to 44%
• Mean length of stay decreased from 3.5 to 3.3 d
• Mortality among ICU patients was unchanged
Strauss et al., 1986 (66)1Admissions to the ICU during times of relative bed shortages (one empty bed) vs. times of relative bed surpluses (three or more empty beds)• On days of high bed availability admissions were less sick (acute physiology score, 52 vs. 61)
• On days of high bed availability patient admissions were less likely to have a primary diagnosis of chest pain (40 vs. 55%)
• On days of high bed availability discharges tended to have experienced longer ICU lengths of stay
• Among discharges, there were no differences in hospital mortality or readmission rate, despite shorter ICU lengths of stay
Stelfox et al., 2012 (67)3Rapid response team calls during times of relative ICU bed shortages (0 empty beds) vs. times of relative ICU bed surpluses (three or more empty beds)• During times of low bed availability there were decreased odds of ICU admission (OR, 0.67) and increased odds of changes in the goals of care on the ward (OR, 1.9), but no change in hospital mortality (OR, 0.91)
• Length of ICU stay and length of hospital stay after rapid response team calls were also uncorrelated with ICU bed availability
Wagner et al., 2013 (68)107Discharges from the ICU during times of relative capacity strain vs. times of less capacity strain• Discharges during times of relative capacity strain occurred after shorter ICU lengths of stay (relative reduction, 0.007 to 0.128 d depending on how strain was measured)
• Discharges during times of relative capacity strain experienced slightly higher 72-h readmission rates (OR for readmission, 1.03 to 1.05 depending on how strain was measured) but no differences in in-hospital mortality (OR for death, 0.97 to 1.02 depending on how strain was measured)

Definition of abbreviations: ICU = intensive care unit; OR = odds ratio.

Constraining the supply of ICU beds in the United States need not require closing existing beds. Instead, we could simply bend the projected bed growth curve by imposing restrictions on new ICU beds. As the population grows, the number of ICU beds per capita would decrease even as the total number of ICU beds remained the same. We could practically accomplish this goal by introducing certificate of need laws at the state level. Certificate of need laws are a widely used strategy for slowing the growth of expensive healthcare infrastructure (70). Certificate of need laws appear to successfully and safely limit neonatal ICU care (71), providing empirical support for their use in adult intensive care.

We acknowledge several limitations with this strategy. First, the ideal number of ICU beds required to care for a given population is unknown. International comparisons could inform this calculation by yielding better population-based estimates of realistic needs for ICU beds and allowing policy makers to observe how varying levels of ICU bed supply impact triage and use patterns (72). Second, clinicians might be frustrated with an inability to admit patients to the ICU at will, because of potential concerns about medical liability, family requests for high-intensity care, and the desire for whatever marginal clinical benefits might be lost for patients who are not admitted. However, just as in all clinical decisions about marginally beneficial therapies, these benefits must be weighed against both the considerable costs of intensive care and the potential harms, such as exposure to multidrug-resistant pathogens and invasive monitors (73).

Finally, careful evaluation is necessary to confirm that the slowed bed growth does not affect quality. Hospitals would need to be prevented from prioritizing profitable uses for ICU beds over uses that are less profitable but equally important (74), and care must be taken to ensure that implicit rationing decisions do not worsen health disparities through unconscious biases based on age, sex, or race (75). Outside the ICU, closing ICU beds would likely lead to an increase in illness severity on hospital wards, with potential for adverse events. To prevent this problem, hospitals could introduce early warning systems to recognize physiological deterioration, a process that is already underway (76). In the emergency department, closing ICU beds might delay ICU transfer for sick patients (77), an impact that might be mitigated by speeding emergency department throughput in other ways (78).

The current “workforce crisis” in U.S. critical care is in part an artifact of overestimated demand. It is also a result of the misperception of the workforce gap as a physician shortage rather than a mismatch between supply and demand. When viewed as a physician shortage, the natural response is to try to increase the number of physicians, an effort that is not feasible, practical, or affordable. However, when viewed as supply–demand mismatch in a setting of constrained supply, the natural response is to increase efficiency and reduce demand, efforts that, although not easy, are much more desirable.

We can take several steps in the right direction. First, as a field we should immediately stop advocating for policies to increase the intensivist supply. Although motivated by a laudable desire to improve patients outcomes, these policies will not help and have the potential to cause harm by distracting us from the problem of overuse and by overemphasizing the value of critical care medicine relative to other medical specialties.

Second, we should redirect our energy toward developing and testing novel care models that might improve outcomes using the same number of intensivists, including efforts to redistribute the intensivist supply, improve quality without intensivists, and increase the efficiency of critical care (79).

Third, we should take steps to significantly slow the growth of ICU beds. Initially, we should test these efforts in integrated healthcare systems that can easily limit their ICU bed supply and quickly transfer patients to referral centers in times of strain (80). Later, we should introduce certificate of need laws that would prevent ICU bed expansion and ultimately lead to reductions in the per capita bed supply.

Fourth, we should update past workforce planning analyses with more robust estimates of future critical care supply and demand. These analyses should test a range of assumptions about the potential impact of new ICU organizational models, the effect of constrained ICU bed supply on patient outcome, and the changing role of the nonphysician clinician workforce. Although no workforce projection is definitive, these analyses can inform the critical care community as to the true scope of the problem and help us estimate the relative effectiveness of alternative strategies to better match critical care supply and demand.

No matter how we proceed, in the coming years we will be faced with tough choices about how to allocate increasingly scarce healthcare resources. The United States is consuming healthcare and intensive care at an unsustainable rate, and as aptly stated by the renowned economist Herbert Stein, “things that can’t go on forever, won’t.” Both supply-side and demand-side solutions are necessary to solve the problems facing critical care, lest the system itself collapse. Our task is to prevent such a catastrophe not by increasing the intensivist supply but by safely minimizing marginally beneficial intensive care and by improving the quality of care to all patients whether they receive care from an intensivist in an ICU or not.

The authors gratefully acknowledge the assistance of Scott D. Halpern and Theodore J. Iwashyna in critiquing earlier versions of this manuscript.

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Correspondence and requests for reprints should be addressed to Jeremy M. Kahn, M.D., M.Sc., Associate Professor of Critical Care and Health Policy and Management, University of Pittsburgh, Scaife Hall, Room 602-B, 3550 Terrace Street, Pittsburgh, PA 15261. E-mail:

Originally Published in Press as DOI: 10.1164/rccm.201408-1477CP on December 4, 2014

Author disclosures are available with the text of this article at www.atsjournals.org.

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