Some comments on where critical care medicine is headed in the next ten years

Recall several months ago I wrote some editorial opinions on where IIF thought critical care was headed, some of them not too kind. I foresaw a critical care world full of Physicians Assistants (PA) and Nurse Practitioners (CRNP) doing patient care and critical care physicians as their handlers in executive roles. The actual experience and training of the critical care fellows to do that more and more attenuated as they eschew night call and direct patient care the PAs and CRNPs are more than happy to provide.

I see it already in the surgical specialties. I saw the guy that fixed my ruptured Achilles Tendon once, the day of surgery. Everything thereafter was handled by his PA. No way to contact him even if I wanted to. I saw the guy that fixed my femur fracture once, the day of surgery. The followup visit three weeks later was handled by his PA.

I was told a while back by the head of our Department who happens to be a long time personal friend that my weakness was that I wasn’t into teaching the fellows the algorithms and protocols that are ruling critical care, and that direct patient care is becoming overrated as it really won’t be done by physicians much anymore. It will be “directed”. the critical care physicians job will be to know every possible parcel of literature and to be involved in some form of research, because that’s where the institutional prestige (and probably money) is.

My response to that was that the directorial critical care physician will be more of a figurehead as he or she gets less and less hands-on experience, especially at night when all disasters happen. That’s, of course, not to say that these people won’t do an outstanding job. It is to say that either you’re a physician and trained as such or you’re not. That distinction is becoming more and more blurred.

So, as I go down the road, predictably this Paradigm is bearing very visible fruit in my case. First time ever, my “faculty reviews” broke the bottom end of 4 (5 being the highest possible). 3.8 for this partial year (this year has been tough for me). That means bottom end of “Very Good” because of a number of “satisfactory” marks given me (3.0).

Now, you have to understand that this is a lot like “Officer Efficiency Reports” in the Army. If a guy gets a completely fair report, his career is over. The only acceptable report is hugely inflated, and mostly bullshit. Pretty much the same here. The report detailing the statistics for all clinical attending here glows for anything over 4.25 and anything under 4.0 is mentioned only as an anchor dragging the Department down.

So, if you examine my strength and weakness numbers, you see that my highest numbers are involved with the issues of (quotes) “Faculty should promote patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health”. “Faculty should promote knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care”. Faculty should demonstrates respect, compassion, integrity, and altruism in the maintenance of professional relationships with patients, families, and colleagues. Meets all professional responsibilities with regard to patient care. Highest score: Faculty explains the ethical, economic, and legal aspects of Critical Care Medicine as well as the psychosocial and emotional effects of critical illness on patients and family”. Creates an appropriately relaxed, cordial, positive, and stimulating learning environment. Briefly reviews expectations of the fellow at the beginning of the rotation or at the start of time on service.

Lowest scores: “Faculty should promote the ability of trainees to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence.” These scores were low enough to bring my average down below 4, first time ever. A fairly dramatic change from years past.

I’ve cherry picked here as much of this is much more complex but I give you the skinny. What’s happening is that the CCM Fellows are being told what is important. What is important is less hands on direct medical care and more ability to honcho others to do it based on current literature cites and research data. If they don’t feel they are getting what’s important, they downgrade those they don’t think are giving it to them.

So, I think it is happening and it’s happening fast. My fear is we are graduating more intelligent, intuitive doctors that have less and less experience in dealing with direct patient care and more experience bringing forth the latest cite on any subject. Direct patient care will more and more be done by non-physicians. . Unclear where it ends and what the sudden, unexpected aftermath will be. Maybe it will work out fine. If so, the curricula of medical college will begin to approximate that of PhD programs.

Comment:  Much of what has happened is a result of supply, demand and market forces here in the south. Few intensivists, fewer who will choose to be up all night, and relatively plentiful NP/PA who value training and practice in critical care.

This has been a steady process of deterioration here for the past few years and fighting it is impossible since prospective fellows can choose to enter a “Pulmonary, Allergy and Critical Care” fellowship that has NO night call and get jobs identical to those coming out of multi-disciplinary fellowships that demand night call as a learning experience. We actually started seeing a deterioration in qualifications in our applicants until we cut back on night call. I think currently they have to do one night a week and at the rate we are adding PAs/CRNPs, most of that is just hanging out watching other people work.

Comment:  Our challenge becomes finding an effective and efficient strategy to train up those physicians who are willing to work hard to an ever higher standard. My bias–and this is a personal, not corporate bias–is that we need to get to progressively more realistic simulations that expose trainees to more problems and issues in 4 hours than we ever encountered in a fortnight.

I think the pool of those would-be physician trainees is dwindling and dwindling fast. In fact, physician trainees willing to deal with the hassles of direct patient care is dwindling. Why should they. Nuclear medicine and radiology specialists are well paid and they all go home at five. Physical Medicine and Rehabilitation. Rheumatology. Sleep medicine. Hematology. Physician trainees are choosing specialties that come with a built in barrier to being bothered after hours.

So we are building a full compliment of clinical intellectuals who know everything there is to know about subjects that fully insulate them from after hour disasters. Who’s there in the middle of the night when the dying happens. Emergency Physicians, but they are normally not credentialed for in-house care. Hospitalists? Jury out. It will be PAs and CRNPS because it seems they are more affordable. The legacy of affordability has yet to be confirmed but I see the hazy vision as it forms.

Comment:  One view is that the technology to achieve this is “too expensive”. Another view is that whoever pulls it off could create a national sim center that operates around the clock for primary and recurrent training.

This is another factor I’m seeing come to fruit here. My medical students all look at their watches mid-morning during or after rounds and decry they are late to the “sim-center” where presumably they spend the rest of their day. I am on record that if the day ever comes and it might, that students get most if not all their time dealing with clinical emergencies via simulators, we are all in deep, deep trouble indeed. The worst possible place to end up would be a hospital where providers translate virtual reality to real reality.

I landed in a hospital in the middle of the night with a femur cracked from stem to stern, a hematocrit dropped to 26 and hypotensive. Even as a long term attending physician at this institution I took pot luck when it came to a provider that knew how to deal with this issue. When Dr. X cruised into my room, had a look at me and the films and told me he’d take care of this I could have kissed him. By the time I got to the operating room it was something like 4 am and he’d been operating all day. The conversation in pre-op went like this : “Him (Putting his initials on the skin of my leg): “you up for this?”. Me: “better question- YOU up for this?” Him: “(stretching)…..You bet. Lets get this done”. Four hour procedure started at 0400 hrs, masterfully done.

Young guy seven years out of his fellowship in trauma and orthopedics. Literally putting my life and my future ability to ambulate in the hands of someone I don’t know. Trusting him with my life and livelihood? How long do you think we’re going to have these spirited guys willing to beat themselves to death for the benefit of people they never saw before. I genuinely fear we are not headed for more of them.

Comment:  I do not think there’s much point in bemoaning the new division of labor. We need to consider how to concentrate training and broaden experience at the same time. At risk of sounding like a “broken record ” (for the younger list members, please Google this archaic expression), aviation figured out the importance of high-fidelity simulators a while ago.

Dealing with the infinite clinical nightmares all conspiring at the same time is NOT like high resolution avionic training. I genuinely fear for sick people in ten years. Hospitals may or may not have the ability to care for them. I am not optimistic, Tim. Making the best of an inherently bad situation for the worst possible of reasons (diminishing funds) isn’t the same as streamlining provision logically and intuitively.

Here’s what I see happening to critical care in the next ten years.

  1. Insurers will become more and more tight with funds as they discover the multitude of patients transferred to ICUs simply to die after a massive wallet biopsy to chronicle their impending demise. But politically, it’s impossible to “say no” to it so they will find other ways co cut funds for “critical care” that can’t be traced back to bean counters. As a result, the time and energy needed to prove admissions are deserving of “critical care” will become progressively ponderous and difficult. Critical Care physicians will become experts in reimbursement policy and will spend most of their time doing it.
  1. Most if not all of the clinical catering will be accomplished by mid-level providers, PAs and CRNPs, and they will all do a great job because if for no other reason most of the day-to-day patient care isn’t all that intuitive. Busy work looking after numbers, cultures, vitals and so on. Acute decompensation in the middle of the night will be addressed mainly to keep the patient alive until morning when higher levels of expertise will come to bear.
  1. I have always said that the day will come when I can tap into a huge global multi-million patient data base, punch in my patient’s particulars and show the family what the real mortality will be and when it will occur no matter what treatment is afforded. I think that day is close. Similarly, that same data base could be used to create algorithms and protocols showing the best possible outcome according to how those millions in the data base did with any treatment scheme.
  1. Accordingly, morning rounds will consist of input from executive levels of critical care physicians who will select the proper clinical protocol for the patient to be on. Protocols based on “evidence based medicine” (consensus of journal articles on the subject), and there will be one for every possible disorder. Respiratory, cardiac, gastrointestinal, neuro and do on. Of course there will be a trailer at the end of each suggesting that they may be modified by “clinical judgment”, but since the critical care attending has long since lost any experience in clinical judgment, that won’t matter. Variations of response to protocols will be met by more protocols, and if the patient dies, it will be because he had no ability to respond to good, standardized care.

As medicine becomes more complex and the information base has increased beyond the ability of individuals to contain it, we go more to the tender mercies of collective clinical judgement (from the literature). Individual clinical judgment is not amenable to control or standardization which is a situation that can’t be condoned.

When I walk into a patients room, the entire ambiance of illness and infirmity flows into my own personal database. I see and feel things that only someone who has spent 35 years at the bedside sees & feels and I intuitively know a lot of things that I don’t need to test against a computer database of the literature to see if it’s valid for THAT patient.

However, I might be wrong because I also have human frailties. And if I am wrong, then my wrongness will be measured by the database of “evidence based” literature which will always be right, especially since it didn’t need to be consulted for THAT patient.

So, current thought is that in the end, everything will be measured by “evidence based” data. The BEST chance for success is to plug everything into a protocol that reflects “evidence”. Although sometimes brilliant, individual care plans suffer from poor quality assurance. Sometimes they can be lousy and there isn’t sufficient ability to separate the two.

So, the whole point of a protocol is that’s it’s uniformly followed to the letter. Deviations result in uncertainty which cannot be condoned. It’s like letters from the Internal Revenue Service. A half page informing you that money is owed and you have been identified as the person owing it, then five pages of what they’re going to do if you don’t pay up.

Protocols are not for thinking processes of whether they should be followed. Protocols are to be followed or those refusing will die the death of 1000 meetings to explain why to stern faced administrators.

Are protocols a good thing that will improve patient care. Unknown. Will be eventually seen. My personal brand of clinical intuition is clearly dead and if I last the next couple of years before forced retirement, I’ll be lucky.

I am the last of my kind.

  1. There will be no place for medical education as we understand it in this scheme. There will be no point in medical students dealing with these patients because they are cut out of the protocol loop. Medical students will spend 90% of their time on simulators watching the numbers fly by and the robot twitch. Any direct patient care performed by resident staff or medical students will be for routine hospital care. Anything resembling an emergency for a hospital patient will be dealt with by mobile emergency response teams who will arrive at the bedside to usurp the continuity of the previous trainees who will observe the goings-on from the back of the pack.

That this will occur (and is occurring now) is a lead pipe cinch guarantee unless……………..

The big joker in this deck is now political. (FL now suspends previous prohibition against political diatribe temporarily because it is integral to this discussion).

As the cost of health care continues to escalate and the reimbursers continue to find novel and bulletproof ways to cut funding for it, the “real” predictions of how this will all go are just that. The scenario I presented above is what’s happening right now and what will progress all other factors remaining equal, but other factors will not remain equal. Everything is now changed as of the mid-term elections where we now have a radically different power structure and a VERY unclear picture of what the Presidential situation will be in 2016.

The Affordable Health Care Act of 2008 was created to do several important things including to make health care portable and affordable by spreading the cost over all those involved. This became a political football and as of today survived those who would destroy it. However, the barbarians previously at the gate are now in charge and so it is now very unclear whether the AHCA will survive. If it doesn’t, and it may not, then we will drop back to our previous system of “private” insurance for those not eligible for Government health insurance. That insurance has been in the process of escalating the cost of indemnification yearly to as much as 50% a year and will continue to do so as long as demand exceeds supply until it collapses under it’s own weight. When it does, there is nothing else in sight for non-Medicare and Medicaid patients other than “self pay” which guarantees instant lifetime financial insolvency for a routine illness requiring hospitalization or surgery.

I also believe then that if the AHCA fails, the next step is European style National Health Service, which is the ultimate affordable system. It gets X amount of $$ and that’s it. Use it wisely. If and when that occurs, my previous predictions above are dashed on the rocks and we will be sailing through completely uncharted waters.


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