Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow

Abstract

There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest.