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To the Editor: I am surprised that Dr Pronovost and colleagues¹ did not mention 2 trends that are exerting a powerful influence on ICU care in the United States.

The first of these trends is the rapidly growing hospitalist movement. Approximately 7000 hospitalists practice in the United States, a number projected to grow to 19 000 in the next few years.² Several studies have demonstrated significant improvements in efficiency and outcomes when hospitalists care for general hospitalized patients.³ A second trend is the projected massive shortage (35% by 2030) of intensivists in the United States.⁴ This magnitude is so large that even substantial increases in ICU training programs cannot stanch it for the foreseeable future.

The convergence of these trends has resulted in hospitalists caring for hundreds of thousands of ICU patients yearly, often under intensivist consultative arrangements that Pronovost et al would characterize as "high intensity." More than 80% of . . . [Full Text of this Article]

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