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Nurse practitioners replacing young doctors: it works, but does it make sense?

Skinner et al. [1] present a well-written paper dealing with the issue of nurse practitioner cover of cardiac surgical intensive care units (CSICU). The motivation to write this paper was driven by (i) economic considerations, i.e. to investigate whether money can be saved without compromising quality of care, if the CSICU is covered without physicians, (ii) the restrictions of the European Working Time Directive, which limits the hours available for junior doctors to spend for their training, and finally (iii) by the unfulfilled expectations of junior surgeons when working on a full-shift rota with residency on CSICU at night and at weekends, since it restricts time for theatre training opportunities. This implies that the anticipated [1], or in some places already existing, shortage of junior doctors in cardiac surgery is another, albeit not mentioned, fact leading to the model of running the CSICU without doctors being present at night. The good news of this paper is that this model worked very well: money could be saved, the quality of care was roughly the same and doctors were much more content being on call than being on a CSICU. The first result is in line with the experience of senior cardiac surgeons having spent some years on a CSICU, which shows that well-trained nurses can usually handle the care of a patient after cardiac surgery better than any newcomer on CSICU and sometimes even better than trained cardiac surgeons, who prefer to be in the operation theatre rather than spending their time on a CSICU. Additionally, it corresponds to the results of a review on this subject [2] and the results of a study directly comparing residents with nurse practitioners [3]. The bad news is that the results of this paper cannot be readily transferred to other European countries, since it is focused on UK practice. First, advanced-care practitioners frequently earn as much money as junior doctors in other European countries do, payments that may not be affordable for every health care system. Secondly, there are some restrictions regarding coverage of a CSICU without physicians by current laws and reimbursement rules in other countries. For instance, in Germany all ICUs must be covered by doctors trained in intensive care medicine. In addition, from 1 January 2013, ICUs must have at least one boardcertified intensivist who supervises treatment to be reimbursed for patients with prolonged treatment on an ICU. However, is this really bad news? Clinical outcome is the most important issue in cardiac surgical intensive care medicine, but not the only one. There are educational and strategic considerations as well. For instance, the consequence of realizing a program as described by Skinner et al. will be that junior doctors may lose or even may never gain the competency in covering a CSICU due to the lack of training. In fact, reducing training in CSICU is already a plan in Europe, at least in a recently published paper on future directions in training cardiac surgeons: ‘One of the changes to improve training opportunities may be to limit the amount of time trainees spend providing service cover for postoperative care in intensive care units ...’ [4]. In addition, by reading the papers about how younger doctors think about the problems of their training, there is no word about intensive care [5, 6], which may suggest that intensive care medicine is no longer considered an integral part of cardiac surgery. However, our US American colleagues have noticed that improving cardiac surgical intensive care by implementing standards decreases mortality after cardiac surgery [7]. Consequently, they now propose a special training program in cardiac surgical intensive care medicine underlining the importance of gaining an intimate knowledge of intensive care medicine for a comprehensive training in cardiac surgery [8]. It is up to us senior cardiac surgeons to increase the interest of our junior doctors in this field, to communicate that intensive care is an essential part of cardiac surgery, and to corroborate this by creating attractive positions for cardiac surgeons performing intensive care medicine. Finally, we have entered an era in which economic considerations primarily aimed at decreasing cost and increasing earnings become increasingly more important in daily clinical practice. Some may even feel that economics rule this practice. If I were a hospital manager, I would love to read this paper, since it is an excellent argument to reorganize staffing of the ICU in my hospital, which will reduce cost. However, the question remains, if we as cardiac surgeons should like this message. In summary, it is important to know that CSICU can be covered by well-trained and experienced nurse practitioners at least for some parts of the day without compromising the quality of care. This knowledge will result or has already resulted in a teamcentered approach to many CSICUs worldwide with physicians and non-physicians working closely together more or less at eye level. However, this is no argument against our duty to train younger doctors in cardiac surgical intensive care. If we lose competency in