Where did all the jobs go?

In the current issue of the Journal, St-Onge et al (1) (pages 93 to 95) present the results of a survey regarding career preparation and expectations of residents in Royal College critical care medicine training programs. Two of the authors were such residents at the time and we commend them for their leadership in addressing important questions. The survey had a response rate of 85%, which is exceptional and perhaps a reflection of the obvious importance of the subject to the respondents.

An apparent contradiction from the respondents to the survey was that 96% expected to work in an academic or combination of academic and community centre while acknowledging that they may require additional subspecialty or academic training to make them more competitive for an academic position. As stated in the documents of the Royal College for the subspecialty of critical care medicine, “…individual residency programs must focus on the knowledge, skills and attitudes pertinent to the expected roles and competencies of the adult critical care medicine specialist”. To date, the primary objective of training programs has been to have trainees develop a level of expertise to enable them to function as independent intensivists. As part of that skill set, there is the recognition that one must be skilled in the intrinsic competencies, such as manager and communicator, as well as being a medical expert regardless of whether it is in a community or academic setting.

After obtaining Royal College certification in critical care medicine, what are the opportunities and realities for employment? The recent Royal College report on physician employment reported that 23% of new certificants in critical care responded that they were unable to find a job (27% response rate) (2). This is consistent with the perceptions of limited prospects reported in the survey by St-Onge et al (1). There are certainly inadequate data for workforce planning in critical care. Challenges to workforce planning include the relatively recent subspecialty recognition; therefore, many physicians providing service to critical care units may not be certified but have clinical experience. All critical care subspecialists have a core specialty that they may also practice to varying degrees. Because extracting data is complicated by a lack of specialty designation in all provinces, billing data cannot be used (ie, Ontario Health Insurance Plan billing codes are not exclusive to the critical care subspecialist).

Although not detailed specifically (2), it appears that there is less availability across the spectrum of positions in academic settings across the country and in most disciplines. By default, the competition for such positions becomes more intense. Although it may have been possible in previous years to secure a position in an academic setting after completing an area of subspecialty training, this is becoming less likely in many disciplines and certainly in critical care. It is no longer adequate to have performed some teaching as a resident and dabbled in research during training if a trainee wishes to secure an academic position. A candidate will bring more to the table if they have additional training (eg, MSc or MEd), which is being used to pursue scholarly activity.

The literature demonstrates that patient outcomes are better when management is guided by an intensivist (3). Intensive care units (ICUs) are also more efficient when they have a dedicated intensivist medical director. However, many of these ICUs still do not have a full complement of certified critical care subspecialists. Thus, we believe that the largest opportunity for employment lies within community hospital ICUs. To reconcile this with the aspirations of trainees expressed in the survey, we recommend that community-based rotations be emphasized in training programs. This will also require that community-based intensivists function as teachers and educators, which may satisfy the desire for academic activity within a community practice.

Some concrete actions that the Canadian Critical Care Society is undertaking to address the manpower issue includes creating and maintaining a directory of ICU medical and administrative leaders; using this contact list to generate a manpower status report; continue posting job openings on our website (www.canadiancriticalcare.org); and supporting the training and preparation for academic careers through activities such as resident days at national meetings such as the Critical Care Canada Forum and the Canadian Critical Care Trials Group.