Physicians here say the practices of pulmonary and critical care medicine are having trouble catching their breath, amid rising demands from an aging population for care and a national shortage of specialists in those areas.


The number of doctors who specialize in pulmonary and critical care in Spokane has dropped from roughly 15 in the early 1990s to about 11 this year, physicians say. Meanwhile, the number of elderly and seriously ill people who require longer hospital visits and more complicated surgical procedures, both of which can require the services of such doctors, has climbed. Although pulmonary and critical care physicians here have been trying to recruit more to the area, a nationwide shortage means theyre working longer hours instead of being successful at bringing in more of their brethren, and new patients can wait two months to see a physician.


Absolutely, there are too few people for an area this size doing the kind of medicine we do, says Dr. John Naylor, of Northwest Pulmonary PS. This is a regional problem, because if Spokane doesnt have enough pulmonary doctors, it has a huge impact on a host of other fields.


Pulmonary physicians deal with diseases of the lung and respiratory tract, while critical care physicians provide greater than ordinary care to patients in critical or unstable conditions. Their disciplines often are intertwined because pulmonary doctors manage ventilator machines, which usually are needed for patients who are in critical condition. The shortage is significant for patients because critical care doctors take care of the most seriously ill patients in what is generally the most expensive and resource-intensive area of medical care in the U.S.


Pulmonary physicians have to attend four years of medical school, complete a three-year residency in general internal medicine, then complete at least two years of subspecialty fellowship training in pulmonary medicine, and often they have additional training in critical care, Naylor says. Historically, pulmonary doctors began practicing critical care when ventilator machines became used more frequently during surgeries.


Nine certified internal medicine doctors who specialize in pulmonary and critical care are practicing in Spokane County, says Jan Monaco, executive director of the Spokane County Medical Society. A few other doctors practice critical care, but havent received critical care certification, Monaco says. Two pulmonary specialists recently retired, another has moved to Seattle, and overall, the number of those physicians has decreased significantly since the 1990s, she says.


You can only stretch the rubber band so far, Monaco says. Our pulmonary and critical care doctors are approaching retirement age, and recruiting any new doctors to this area is impossible.


Northwest Pulmonary has been trying to recruit a pulmonary and critical care specialist for the past seven years, Naylor says. The practice currently has five doctors, two of whom are there on a temporary basis.


One of the difficulties in recruiting such physicians is that fewer U.S. medical students are interested in the subspecialties of pulmonary and critical care, Naylor says. About 60 percent of the fellowship-trained doctors who took the pulmonary and critical care certification board exams last year were foreign-born, and they tend to return home to practice medicine, he says.


Residents see that the job is demanding, and that the hours are long and chaotic, says Naylor, who typically works 80 hours a week. Cardiologists work hard, too, but at least in Spokane, theres more of them to handle the load.


Theres also a funding shortfall for residencies and fellowship training slots for certain subspecialties, including pulmonary and critical care, he says. The federal government provides subsidies to hospitals that have teaching programs, but since the early- to mid 1990s, it has been scaling back funding for subspecialty training, he says.


Although the shortage is occurring nationally, pulmonary and critical care physicians here also are having difficulty recruiting fellow doctors because salaries are relatively lower in Washington state than in the Midwest or the South, he says. Medicare and private insurers have reimbursed to physicians in this state at a lower level than doctors elsewhere, he says.


The quality of life in Spokane, rather than average physician salaries here, has become a selling point when recruiting the specialists, says Dr. Sam Joseph, of Spokane Respiratory Consultants PS. That practice currently has five physicians, and for the past year its been trying to recruit three more, Joseph says.


Its certainly gotten busier in the last four years at our office, he says. It reflects that there are fewer people doing the same amount of work, and theres more work to be done.


Each year, 2,500 pulmonary and critical care positions are open in the U.S., while only about 600 newly-trained physicians are available to fill them, he says. Meanwhile, doctors are retiring and arent being replaced. Most of the pulmonary and critical care specialists in Spokane are above age 50, and the long, frequently nighttime hours required for the job are becoming more difficult to maintain, he says.


The general population is aging, too, which adds to physicians workloads, Joseph says.


Were stretching the envelope for who gets operated on, including the elderly and morbidly obese, he says. It creates a higher intensity of care for inpatient procedures.


Since the early 1990s, many pulmonary and critical care doctors have been getting certified in sleep medicine as well, which creates a lot of balls to juggle in terms of specialties, says Dr. James Osmanksi, of Pulmonary Consultants North Idaho, in Coeur dAlene. Osmanksi also is the medical director for the intensive care unit at Kootenai Medical Center and co-director of the KMC Sleep Center.


Sleep has become a hot-button issue, Osmanski says. Sleep and sleep processes have gained recognition for their importance to other systems, such as the brain and the heart.


The supply of pulmonary and critical care physicians in North Idaho has kept pace with demand, although the national shortage of doctors in all medical fields is concerning, he says. Pulmonary Consultants has five physicians, and has been recruiting for two years. It added a doctor last year, and shortly thereafter decided it needed to recruit another one, he says.


Study foresaw problem


Osmanksi, as well as other physicians here, cite a study that was conducted in the late 1990s and published in the Journal of the American Medical Association in 2000 as evidence that a national shortage was predicted several years ago. The study, conducted by a group called the Committee on Manpower of Pulmonary and Critical Care Societies, or Compaccs for short, evaluated patient demand and physician supply for pulmonary and critical care to predict future demand and supply.


It showed that as a result of an aging population, demand for care would surpass the supply of physicians by 2007, and would exceed supply by almost 35 percent by 2030. It analyzed variables such as changes in the numbers of intensive care diseases, changes in the numbers of trainees, and physician retirement age. The study found that the only variable that would equalize demand and supply in 2030 would be to delay the age of physician retirement to 77 years old.


The study was sponsored by four national organizationsthe American Association of Critical Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine. After the study was completed, those four groups formed the Critical Care Workforce Partnership, and representatives of that group met with members of the U.S. Congress to show them the Compaccs study.


In its fiscal year 2003 appropriations bill, the Senate said it was concerned about a looming shortage of pulmonary and critical care specialists. The Senate asked the U.S. Department of Health and Human Services to work with the partnership to develop a plan to address the crisis. Since then, several task forces have issued recommendations for addressing the problem.


Joseph says governmental agencies need to increase funding for training, although that would be a long-term solution, because even if more training slots were opened immediately, a few years would pass before students who filled them finished their training. In addition, he says, partnerships between hospitals and doctors are important in providing an attractive workplace for recruits.


Naylor says hospital administrators are starting to realize they need more pulmonary and critical care physicians to handle rising patient demand. Northwest Pulmonary has been working with Spokane-based Empire Health Services Inc., which operates Deaconess Medical Center and Valley Hospital & Medical Center, to devise a recruitment package to try to attract more doctors.


Hospitalists, who provide care solely at hospitals rather than splitting their time between a private practice and the hospital, probably will become more prevalent as demands for critical care increase, says Dr. Todd Green, of North Spokane Pulmonary. That practice, which includes Green and a foreign medical school graduate whos living here on a visa, needs two more physicians and has been trying to recruit them for five years, he says.


Green says he enjoys taking care of people, but working 12 hours a day during what amounts to a 12-day work week is taking its toll.


What once was an attractive profession is spiraling into something else, Green says.


He says that even though physicians here are working longer hours, patients are experiencing longer wait times, and if the trend continues, it might have more serious consequences for patients.


Were the doctors who take care of the sickest people, he says. At some point there will be a drop off in the quality of care in the Spokane area, and its not too much of a stretch to think that people will die as a result.


Contact Emily Brandler at (509) 344-1265 or via e-mail at emilyb@spokanejournal.com.