The Unacknowledged Transformation of Critical Care Medicine

The history of critical care is a narrative of increasing understanding of what care benefits our patients, delivered in a context that was stable, well understood, and substantially under local control. Now, our understanding of what care patients require is threatened by a variety of disruption in how that care is delivered. New restrictions on duty hours, the expansion of the critical care work force, and the widespread adaptation of the electronic medical record are transforming critical care medicine in important ways, most of which are completely unexamined. As far as anyone can see into the future, there will be increasing demand for care provided by or supervised by intensivists. No matter how you slice the data, the difference between the supply of intensivists and the demand for their services is substantial, and growing. At academic centers, residents have historically extended the care generated by individual intensivists. Trainees allowed a single intensivist to supervise the care of a substantial number of patients around the clock. The benefit to the residents from this immersive and exhausting experience was incomparable; most trainees from that era describe their ICU rotation as the most intense, important, and formative experience of their residency. Restrictions on duty hours have brought this era to a close, and have ushered in a new one of full-employment for physician extenders, such as nurse practitioners and Physician’s Assistants. Resident duty-hours are now so restricted that housestaff generally no longer view themselves as the doctors for