Where Have All the Pulmonologists Gone?

Vol. 15 •Issue 6 • Page 14
Where Have All the Pulmonologists Gone?

Predicted Shortage of Caregivers Causes Concern Today

By the year 2007, the world will be a different place. Perhaps it will be a better world with people living longer. Maybe there will even be a cure for AIDS. But it may also be a worse world, complete with shortages of caregivers, including a shortfall of pulmonologists.1 Three highly regarded associations — the American Thoracic Society, ACCM and ACCP— are already predicting severe shortages in that field.

Five years from now, things could get far worse than they are. Currently the nation’s hospitals are plagued with overcrowded ERs and understaffed ICUs, and RC departments are screaming for new recruits to help with the growing patient population. Critical care units are already in trouble in many areas of the country, and with a dwindling supply of licensed caretakers, the prognosis looks bleak for the not-too-distant future.

The trend does not bode well for patient care. When staff shortages are a reality, existing staff are forced to handle additional patients, and care is compromised in the process.

Sometimes care is being postponed today to detrimental effects. Recently, a middle-aged male entered a small, rural hospital. The staff knew he needed more sophisticated surgery than they could provide, so they arranged to have him transported to a larger urban facility.

Unfortunately, the larger hospital had no vacant beds so the man was forced to remain in his rural facility for several days during which time his condition deteriorated and he died. It was scant consolation to survivors to learn he might still be alive had he been transferred earlier.

Gunshot victims and accident patients took precedence in the urban hospital where the line out of the ER waiting room door seemed unending. That’s scant consolation for survivors either. Yet this is the reality of what already happens today when a hospital is short staffed. These are the quiet deaths we don’t ever hear much about. We might have the best technology in the world, but with no one to operate it, it will do no good.

Two of the busiest areas in medicine today are care of the critically ill and management of pulmonary disease. These two areas are also the most likely to be profoundly influenced by increases in the number of elderly patients in the years ahead. To look at where medicine was headed for the future, the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine formed the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS).

The committee’s goal was to determine current patterns of care for the critically ill and for patients with pulmonary disease, anticipate how demand for care might change in the future and project the manpower needed to handle the patient population based on the current workforce and training.

Specifically the committee wanted to test two hypotheses: first, that changes in the U.S. health care organization will lead to an oversupply of specialists; and second, that changes in the demography of the U.S. population will lead to an undersupply of specialists.1

“It may get worse before it gets better,” .concluded George G. Burton, MD, senior pulmonologist at Kettering Medical Center, Kettering, Ohio. That does not mean it is a hopeless situation. “Respiratory care professionals can step up and help the pulmonologist by acting as physician extenders. If we wait for pulmonary physicians in training, we will be waiting a very long time,” he added.

There is no better time than the present for RTs to educate doctors on how therapists can assist a pulmonary physician, Burton stressed. “If there is a doctor in training and he does not know what a good therapist can do and how he can help, it is not good,” he said. “Fewer and fewer doctors are going into the pulmonary specialty. There is a great concern about how we will fill these gaps in manpower.”

There is a recognized need for more education. “Pulmonary physicians in training do not have any idea what respiratory care practitioners do,” he added. “The committee findings showed that residency review com.mittees never required pulmonary fellows to spend time with respiratory care services. “They spend time in bronchoscopy procedures and pulmonary function labs,” Burton said. “Respiratory doctors really need to know what respiratory care practitioners do and should rotate through an RC service.”

While a lack of knowledge is one side of the coin, there is another ominous side of the picture. Pulmonologists and physicians in general are retiring earlier, leaving a lot of work hanging in the balance. “A lot of the physicians I know are retiring because of the stress involved,” said Burton who is still working at age 68 because “there is still so much work to do.”

Doctors encounter problems with the pulmonary care field even as they get set to embark on their careers. Doctors undergo years of training and pile up a mountain of debt before they even launch their practices. To defray some of the cost, they rely on fellowships, but these are difficult to obtain even though the budget for the National Institute for Heart, Lung and Blood has gone up. As a result, “there has not been enough money to train these people,” Burton said.

Fast forward five years, and this is what we can expect. “There will be a shortage of pulmonary experts in 2007 because of the aging population,” said Marchant Wentworth, director of Health Care Policy for the American Thoracic Society (ATS). It takes about seven years to build a specialist, and currently there are few people stepping to the plate.

“Where are these intensivists going to come from?” Wentworth wondered. “People are completely stressed out and overworked now in the ICU. There is just no way for them to be instantly produced. We need to take action to train more intensivists.”

He attributes some of the problems to the lack of payment for care. “The reimbursement rates for CCU/ICU physicians are too low,” Wentworth said. “Residents are looking at a whole set of criteria, and one is money. The other issue is the work place environment. You are asking new graduates with a lot of medical debt and training to be ICU specialists where they would have to give up weekends and work odd hours.”

Remedies need to be made within the hospital setting in order to retain the staff too. “We have to increase reimbursement rates and internally fix the staffing so people are not working insane hours,” he added. Changes need to come from hospitals, state and federal government, he noted.

Ronald Stiller, MD, PhD, clinical assistant professor of medicine at the University of Pittsburgh and member of the pulmonary department at the University of Pittsburgh Medical CenterÐShadyside loves his job working with critical care patients and works insane hours.

“I’m 55 years old and sleep over in the hospital once a week,” said Stiller who agrees there is a lifestyle problem involved with treating critical care patients. On a cautionary note, he said the field is not necessarily one for younger physicians planning to start families. “This is not a profession that goes well with being a new parent,” he said.

There is also a negative image to overcome. “If you talk to pulmonologists who are doing critical care medicine, I think they feel beat up, and that may discourage new people from coming in,” he said. “I think the message of academic medicine coupled with the demands on the clinical guys already out there may work hand in hand to limit the numbers.”

The field must also compete against the “glamour jobs.”

“Whenever anyone goes to a major institution for training, the emphasis and focus is on academic medicine and research,” Stiller explained. “There really is a stigma to being a LMD (local medical doctor).” The notion is somehow out there that “if you can’t cut it in academics, you’re probably not as good as the rest of the guys,” he explained. “I think there is a pressure in terms of training not to become an LMD.

The University of Pittsburgh Medical Center-Shadyside has a well known pulmonology program, Stiller pointed out. As a result, Shadyside is extremely busy and occasionally the doctors send out S.O.S. messages. “Occasionally we get some of the university pulmonary guys to come help us out, but that is discouraged because they should be in the lab and writing. They should not have anything to do with critical medicine,” Stiller said.

Then there is the age-old problem. “The ICU is not conducive to a really fantastic life outside of the hospital. We spend lots of time here,” he added.

Although staffs are short now, some veterans in the field believe the situation will lighten up as money starts to flow to curtail the staffing drought. “Right now we are hurting big time,” said Stiller, who is not likely to change what he does in the years ahead.

“I really like what I do,” he mused. “I love the ICU. I like dealing with critically ill patients. There is a broad brush stroke to what we do. We do invasive things to patients. We talk to families of people who are dying. We talk about end-of-life decisions and ethical decisions. We see kids in the office with asthma. It is a very diverse group of things that we do.”

1. Derek A, Kelley M, et al. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease. JAMA (Dec. 6, 2000; 2762-2770).

You can reach Caroline Crispino at [email protected].