Dr. Danny Lewis on how hospitalists are holding rural critical care together

An intensivist shortage has pushed nine in ten rural hospitalists into ICU duty without adequate specialist backup. The physicians keeping community hospitals viable are not the ones the system was designed around.

At 2 a.m. in a 25-bed hospital in northeast Iowa, the physician standing over a coding patient is almost never an intensivist. There is no fellow down the hall, no critical care attending on call, no rapid response team waiting in the wings. There is a hospitalist, a respiratory therapist, two nurses, and a ventilator. Whether the patient lives or is loaded into a helicopter for a ninety-minute transfer to Iowa City depends almost entirely on what that hospitalist knows how to do.

This is the open ICU model, and it now governs an estimated 41% of community hospital critical care programs in the United States. It is not a strategy anyone designed. It is what happened when the supply of board-certified intensivists collapsed against the demand of an aging rural population, and someone had to fill the gap.

The Leapfrog Group has recommended for more than two decades that every ICU patient be managed by an intensivist, pointing to a 40% reduction in ICU mortality when that standard is met. Roughly 23% of critically ill Americans actually receive that care. The remaining 77% are managed under variations of the open model, with hospitalists serving as the primary attending and intensivist input ranging from telemedicine consults to nothing at all.

The open ICU model does not just ask hospitalists to see ICU patients. It asks them to be the intensivist.

Internal medicine literature, summarizing the rural staffing model

A workforce gap that keeps widening

The Society of Critical Care Medicine projects that demand for intensivists will rise 38% over the next decade, driven by an older population and higher critical care utilization. Supply is not keeping pace, and the gap concentrates in the places least equipped to absorb it. Critical care fellowships cluster around academic medical centers in metropolitan markets. Compensation, case mix, research opportunities, and lifestyle pull newly minted intensivists toward the same urban systems, leaving Iowa, Minnesota, the Dakotas, and rural Appalachia chronically understaffed.

A national survey published in the Journal of Hospital Medicine puts numbers on what the workforce already knows. Sixty-eight percent of hospitalists nationwide report caring for ICU patients. In rural settings, that number climbs to 96%. Of those rural hospitalists serving as primary ICU physicians, 85% describe the role as their default responsibility, and 90% report insufficient support from board-certified intensivists. Nearly half say they practice beyond their scope of expertise at least some of the time.

Tele-ICU programs, which connect remote intensivists to bedside teams through video and data feeds, have grown rapidly as a partial fix. They help with surveillance, medication review, and second opinions. They do not place a central line at 3 a.m. or intubate a crashing septic patient. The physician in the room remains the hospitalist.

BY THE NUMBERS

41%  of community hospital programs operate under an open ICU model

96%  of rural hospitalists report providing ICU care

90%  say they receive insufficient intensivist support

38%  projected increase in intensivist demand over the next decade

The physician the system wasn’t designed to produce

Dr. Danny Lewis Jr., MD, is the kind of physician the open ICU model depends on, and the kind the training pipeline produces almost by accident. A graduate of the University of Minnesota Medical School and the Northeast Iowa Family Medicine Education Foundation residency, Lewis spent six years as Chief of Staff and Assistant Medical Director at MercyOne New Hampton, a critical access hospital serving roughly 14,000 people in north-central Iowa. He carried an outpatient panel during the same period.

His procedural skill set reads more like an emergency medicine attending than a traditional hospitalist. Lewis manages ventilated patients, leads code responses, places chest tubes and central lines, performs emergent airway management, and titrates vasopressors on patients running multiple drips. He holds active certifications in ACLS, ATLS, PALS, BLS, and NRP, is licensed in Iowa and Minnesota, and now works as a locum tenens physician through Wapiti Medical Staffing, Highland Medical Staffing, ApolloMD, KPG Healthcare, and Community Physicians Care.

Lewis is board-certified in emergency medicine, which puts him in a category most rural hospitalists are not. The Society of Hospital Medicine’s data shows that more than 70% of hospitalists now perform ICU work, and among those with 20 or more years of practice the figure climbs above 60%. Many came to it through accumulation rather than training, learning ventilator management and pressor titration on the job because no one else was available. Lewis came to it through residency and emergency department experience, and the difference shows in what a community hospital can keep in-house when he is on shift.

Why continuity is the open model’s hidden advantage

Closed ICUs, the staffing model dominant in academic medicine, hand patients off at the ICU door. A new attending assumes care on admission, then transfers the patient back to a different physician on discharge. Each handoff introduces information loss and the risk of a goals-of-care conversation being repeated, contradicted, or skipped.

Open ICUs preserve the relationship. The hospitalist who admitted the patient continues to manage them through critical illness and back out to the floor or home. A qualitative study published in the Journal of General Internal Medicine found that hospitalists in open ICU environments reported stronger longitudinal relationships with patients, smoother transitions, and better visibility into the full arc of disease.

At MercyOne New Hampton, Lewis often knew his ICU patients from years of clinic visits before they ever became critically ill. He knew their baseline cognition, their family dynamics, the advance directive conversations from the previous summer. That context shapes decisions that data alone cannot. Whether to escalate a septic 84-year-old to intubation is a different question when the physician has spent two years discussing what the patient wants.

When the right physician is at the bedside, the open ICU is not a compromise. It is the only access to critical care these communities have.

The transfer that does not happen

The clinical case for the open ICU rises and falls on what happens when it fails. A community hospital without a procedurally capable hospitalist transfers its critically ill patients out, usually by helicopter or critical care ambulance, to a regional center an hour or more away. Transfer carries real risk: hemodynamic instability during transport, communication gaps between sending and receiving teams, and the secondary cost of families who suddenly need to travel for a hospital stay measured in weeks.

When the open ICU works, many of those transfers do not happen. Sepsis is resuscitated, cultured, and started on broad-spectrum antibiotics locally. A COPD exacerbation requiring BiPAP or intubation is managed in-house. A post-surgical patient who develops respiratory failure overnight is stabilized without the delay and risk of moving them. The hospital remains financially viable. The patient stays close to family. The receiving tertiary center is not absorbing a transfer it did not need.

Rural hospital closures have accelerated over the past decade, with more than 150 facilities shuttering since 2010, according to the Cecil G. Sheps Center for Health Services Research. The hospitals that have survived are not the ones with the best balance sheets. They are the ones that can keep care local, and that depends almost entirely on the physician workforce in the building.

Rethinking what a hospitalist is

The traditional picture of the hospitalist, a physician who manages floor patients and defers ICU work to specialists, no longer describes what most of the workforce actually does. The Society of Hospital Medicine’s own surveys put hospitalist ICU work at over 70%, and the rural figure is effectively universal. The role has drifted, and training has not yet caught up.

Some academic centers have started offering critical care boot camps for hospitalists, short procedural courses covering airway management, central lines, and ventilator basics. A handful of internal medicine residencies are piloting tracks designed around rural and community practice. Whether these programs can scale fast enough to match the demand curve is an open question. The intensivist shortage is projected to deepen through the 2030s, and the rural hospitals that depend on the open model do not have time to wait for the pipeline to catch up.

Lewis is, in some ways, an answer the system stumbled into rather than designed. His emergency medicine board certification, his procedural training, his decade in critical access hospitals, and his willingness to work locum tenens across multiple rural sites make him precisely the kind of physician the open ICU was built to lean on. There are not enough of him. The healthcare system has not yet figured out how to make more.

The open ICU is not going away. The question is whether American medicine can train, support, and retain enough physicians like Danny Lewis to make the model do what it is being asked to do.

ABOUT THE PHYSICIAN

Dr. Danny Lewis Jr., MD, is a board-certified emergency medicine physician and hospitalist with more than a decade of experience in rural and community hospitals across Iowa and Minnesota. A graduate of the University of Minnesota Medical School and the Northeast Iowa Family Medicine Education Foundation residency, he served six years as Chief of Staff and Assistant Medical Director at MercyOne New Hampton. He was recognized as Resident Teacher of the Year, Academic Chief Resident, and Resident of the Year during training. He holds certifications in ACLS, ATLS, PALS, BLS, and NRP, and is licensed in Iowa and Minnesota.