United States - Private practice: Where are we going?

Abstract

There are two competing models in the United States of America (USA) for delivering critical care services in private practice to intensive care unit patients with life-threatening illnesses. First is the model of consultation practiced by Pulmonary/Critical Care. Patients are admitted to the ICU in the private practice environment by a primary care physician or surgeon and various services are consulted to manage various organ systems in failure. Normally pulmonology is asked to manage respiratory failure and will take care of mechanical ventilation and other respiratory issues. They usually do not manage other organ systems so cardiology takes care of heart problems and nephrology takes care of kidney problems, etc. Under most private practice situations the pulmonologist does not take administrative responsibility for the ICU and does not see all patients in the ICU. The consultation on the ICU patient is only part of the pulmonologist's day since they have many other clinical responsibilities including consults outside the ICU, office practice, sleep lab, bronchoscopy suite, pulmonary function lab, etc. This model represents 85-90 % of private practice situations where the intensivist model is uncommon. The private practice intensivist model places physicians who are fellowship trained in critical care in the ICU as their full clinical responsibility without other clinical obligations outside the ICU. The intensivist usually works 7 days in a row to preserve continuity of care. A team of intensivists cover 16 h/day with a daytime intensivist and an evening intensivist and take night time pager call for the remaining 8 h/day so that there is a ready response from an intensivist 24 h/day. In very busy ICU environments with a high level of severity of illness there is a dedicated intensivist in the ICU 24 h/day.