Intensive Care workforce

In following the convention of corporate buzzwords and inane euphemisms, this chapter uses the term "human resources" to refer to the people you work with. These people are human, and may possess unpleasant character traits.  In fact, the ICU environment seems to be a powerful filter designed to identify and concentrate people with severe personality disorders. The combination of a stressful work environment and perpetual inter-department conflict tends to grind down even the ones who start out normal.

This topic has yet to appear in the college papers. The specific domains of HR which could potentially be examinable would probably have to include such things as the approach to an underperforming staff member, what to do when your staff are depressed or intoxicated, how to protect from burnout and various other such things. 

The Australian ICU Workforce Crisis

Our former college president had (in 2015) authored a review of the Australian ICU workforce, a "workforce survey" if you will, which produced some ugly figures. At a risk of angering the accrediting body, I reproduce these figures below:

Ratio of trainees to fellows in Australasian colleges of various specialties

A few notable points:

  • There is an oversupply of fellows
  • The college in 2015 had 898 active Fellows (including overseas Fellows) and 594 active trainees.
  • Only 30-40% of the trainees go on to actually complete the training program
  • About 22% of recent graduates are “underemployed”, i.e. persist in non-specialist jobs after completion of specialist training
  • The training program is now completely screwed: "recent changes to the selection process for new trainees have been associated with a dramatic reduction in the number of new trainees, from 334 in 2013 to 55 in 2014"; however there appears to be some denial about the disastrous effect of this on future staffing ("the enduring effect of this is yet to be determined", they wrote).

Things to realise:

  • The colleges are legislated by the Australian Competition and Consumer Commission (ACCC) as bodies whose role is limited to education and accreditation, not workforce planning.
  • To limit the intake of trainees would be illegal, and historically the Ophthalmological Society of New Zealand was fined its entire assets when it was deemed to be unfairly limiting “trade” (quoted from Bevan et al, 2015). However, CICM can cheat: "the result of changing [training] standards may indirectly influence the supply of trainees".
  • In 2015, the ANZICS director survey showed a mean demand of 1.3 new positions per ICU over the next 5 years, i.e. 100–150 new full-time specialist positions by 2020. However, there will also be 200–300 new CICM Fellows created over this period.

The Elderly Intensivist

CICM have a lovely "Statement on the Practice of Intensive Care Medicine and the Older Intensive Care Specialist" which addresses the problem of having one's critical care competence degraded by the ravages of age. As one might expect, the statement is strong where it comes to supporting and valuing the "wisdom, perspective and experience" of older intensive care specialists. Where it comes to concerns regarding the safety of practice, they mutter something about "the natural age related decline in motor and cognitive functions" and go on to offer their support in advice and assistance.

This can be contrasted with the treatment of the trainee with difficulties. A 2012 article from the MJA gives us insight into the issues in managing an ageing medical workforce.

In brief,

  • The medical community is ageing in parallel with the population
  • There is evidence that older doctors perform poorly in comparison to younger doctors
  • No Australian specialist college has any policies in place regarding the special circumstances of the ageing specialist.
  • There is evidence that ageing doctors intuitively adopt changes such as such as taking longer with patients, avoiding isolation and areas of unfamiliar practice, and retiring from procedural work.
  • A policy of mandatory retirement would be inappropriate, because of wide individual variations in the effects of age on performance.
  • Competence assessment beyond a certain age may be a good idea, but there is disagreement as to who needs testing, and how to test them.
  • Workload adaptation is the buzzword used to describe the practice of farming the elderly intensivist out to the medical schools, mentorship, administrative duties and research (thus removing them from the immediate vicinity of the patients).



CICM "Statement on the Practice of Intensive Care Medicine and the Older Intensive Care Specialist"

Skowronski, George A., and Carmelle Peisah. "The greying intensivist: ageing and medical practice–everyone’s problem." Medical Journal of Australia 196 (2012): 505-507.

Finucane, Paul M., et al. "A comparison of performance assessment programs for medical practitioners in Canada, Australia, New Zealand, and the United Kingdom." Academic Medicine 78.8 (2003): 837-843.

Papp, Klara K., et al. "The effects of sleep loss and fatigue on resident–physicians: a multi-institutional, mixed-method study." Academic Medicine 79.5 (2004): 394-406.

Dawson, Drew, and Kathryn Reid. "Fatigue, alcohol and performance impairment." Nature 388.6639 (1997): 235-235.

Landrigan, Christopher P., et al. "Effect of reducing interns' work hours on serious medical errors in intensive care units." New England Journal of Medicine351.18 (2004): 1838-1848.

Macas, A., et al. "Stress and fatigue among anaesthesia and intensive care doctors in Lithuania." Critical Care 14 (2010): 1-1.

Parshuram, Christopher S., et al. "Fellowship training, workload, fatigue and physical stress: a prospective observational study." Canadian Medical Association Journal 170.6 (2004): 965-970.

CICM Policy Document IC-5: "Guidelines on the Health of Specialists and Trainees".

Schattner, Peter, Sandra Davidson, and Nathan Serry. "Doctors' health and wellbeing: taking up the challenge in Australia." Medical journal of Australia181.7 (2004): 348-349. Irritatingly, this one is not available as full text, and the abstract merely states that "promoting psychological wellness in doctors requires tailored interventions".

Fortunately, the AMA has some Resources on doctors' health for Australian doctors which contains a comprehensive list of references.

Venkatesh, Bala, and Andrew Turner. "The intensive care workforce summit." Critical Care and Resuscitation 17.2 (2015): 73.

Karnik, Amod, Bala Venkatesh, and Daniel Angelico. "Analysis of performance and predictors of success in the final fellowship examination of the College of Intensive Care Medicine." Critical Care and Resuscitation 17.1 (2015): 47.

Bevan, Rob, Balasubramanian Venkatesh, and Ross Freebairn. "The intensive care medicine workforce in Australia and New Zealand: oversupplied or underdemanded?.Critical Care and Resuscitation 17.2 (2015): 141.

Panagioti, Maria, et al. "Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis." JAMA Internal Medicine (2016).

Maslach, Christina, Susan E. Jackson, and Michael P. Leiter. "Maslach burnout inventory." Evaluating stress: A book of resources 3 (1997): 191-218.

Reader, Thomas W., Brian H. Cuthbertson, and Johan Decruyenaere. "Burnout in the ICU: potential consequences for staff and patient well-being." Intensive care medicine 34.1 (2008): 4-6.

Elpern, Ellen H., Barbara Covert, and Ruth Kleinpell. "Moral distress of staff nurses in a medical intensive care unit." American Journal of Critical Care14.6 (2005): 523-530.

Corley, Mary C., et al. "Development and evaluation of a moral distress scale." Journal of advanced nursing 33.2 (2001): 250-256.

Bakker, Arnold B., Pascale M. Le Blanc, and Wilmar B. Schaufeli. "Burnout contagion among intensive care nurses." Journal of advanced nursing 51.3 (2005): 276-287.

Verdon, M., et al. "Burnout in an ICU nursing team." Intensive Care Med (2007).

Poncet, Marie Cécile, et al. "Burnout syndrome in critical care nursing staff." American journal of respiratory and critical care medicine 175.7 (2007): 698-704.

Embriaco, Nathalie, et al. "High level of burnout in intensivists: prevalence and associated factors." American journal of respiratory and critical care medicine 175.7 (2007): 686-692.