A diagnostic dilemma of syncope.

I appreciate the letter of Drs. Arnett and Orient regarding the COMPACCS, Committee on Manpower of Pulmonary and Critical Care Societies.1 I enthusiastically agree that it would be a mistake, indeed it would be impossible, to “force residents into different subspeciality training programs. . . .” That was never the intent or goal of manpower planning nor the point of my editorial. It is absolutely clear to all practicing pulmonologists and intensivists that, right now, there are more jobs than trained physicians to fill those spots. I believe that the primary-care training initiatives that were mandated several years ago are partially responsible for our current subspecialty shortage. Those far-sweeping initiatives were based on decisions made essentially with no hard data, then “written in stone,” with very little comfirmatory or refutatory data collected. In order to not repeat that scenario, we must make manpower decisions based on data and then, I believe, recheck our data and therefore our assumptions. We would never administer warfarin without checking the prothrombin-time frequently. Why would we obtain a snapshot picture of physician manpower needs and never recheck the data in the future? I disagree completely with the authors regarding the value of workforce assessment. As the COMPACCS article has shown, it is possible to obtain a detailed, methodologically rigorous analysis of manpower needs that, best of all, is completely in touch with our current reality. Periodic workforce assessment should be a part of our response to the dilemma of increased physician demand, which is occurring earlier and more rapidly than even the COMPACCS paper suggested. There is no question that we need to develop strategies to meet these demands, not only now, but more importantly, in the not-too-distant future, when the baby-boomer generation will need more critical care services. Increased numbers of clinical trainees, new strategies of “virtual” intensive care, and evaluation of alternative physician providers in the ICU should be considered and evaluated to solve this important problem.