Alarming reports by the Canadian media highlight how procedures are being canceled or delayed because of a shortage of anesthesiologists, particularly in rural or remote areas. The problem is not new for Canada, Giuseppe Fuda, MD, president of the Canadian Anesthesiologists’ Society (CAS) and vice president of the Association des Anesthésiologistes du Québec, told Medscape News Canada. Fuda is an anesthesiologist at the Jewish General Hospital in Montreal.
How Canada Got Here
“This is not the first time we are in shortages,” said Fuda. “It’s cyclical.… I remember when residents [were] almost crying to me, ‘I’m not going to find a job. Everything is so full everywhere!’ And here we are, a little less than a generation later, and it is the complete opposite.”
“Multiple factors are contributing to this shortage,” said Beverley A. Orser, MD, chair of anesthesiology and pain medicine at the University of Toronto in Toronto. “We have seen an expansion of service requirements due to the increase in the population size, the aging Canadian population, and the availability of additional procedures, diagnostic interventions, and so forth [that require anesthesiologist support]. We simply have not trained enough positions in Canada, and the funding hasn’t been there from the provinces to train people.… We’re seeing a workforce that’s proportionally older, and the working patterns of physicians has changed.” Gone are the days when physicians worked 100-hour weeks and never saw their families.
Burnout is another contributor. Anesthesiologists are relatively isolated within the medical system, and the increasing complexity of patients eligible for surgery has made their jobs more stressful. These issues are compounded in remote or rural settings where support is limited.
- Canadian anesthesiology shortages are causing procedure cancellations/delays, esp rural/remote areas.
- Drivers: ↑ demand, aging population, insufficient training funds, older workforce, changing work patterns.
- Burnout + complex surgical patients worsen staffing strain, especially where support is limited.
- Underused resources: family practice anesthetists, anesthesiology assistants, team-based care models.
- Licensing barriers + weak national workforce data hinder cross-provincial deployment and planning.
Canada failed to address these changes preemptively. “One thing that we’ve done badly in Canada is…predict the demand from the population and how we should supply it,” said Fuda.
“In Canada, we do not have good healthcare workforce data,” Orser agreed. “Figuring out supply chains is not that difficult. Figuring out need and the gap is difficult.”
Underexploited Resources?
The problem has not been ignored completely. Residency programs across Canada have dramatically increased their numbers of spaces. Barriers to licensing for international medical graduates are being addressed, particularly for those trained in countries where the academic rigor is comparable to that in Canada.
The Canadian Health Workforce Network and the efforts of people such as Orser are improving healthcare workforce metrics. In a position statement, the CAS outlined a multipronged approach to addressing the shortage. Fuda initiated the Anesthesia Taskforce to look for creative solutions.
Canada has unique and underexploited resources. “Family practice anesthetists (FPAs) like myself work in rural areas because the volumes are low,” explained Nadia Alam, MD, who has worked in remote regions of Ontario. Canadian anesthesiologists are typically paid on a fee-for-service basis, so many do not want to work in an area where the need for anesthesia services is sporadic. Conversely, FPAs “have translatable skills. They can work as family doctors. They can work in the emergency room. They can work on the inpatient wards.”
Anesthesiology assistants (AAs), typically respiratory therapists or nurses who undergo additional training in anesthesia, are another underutilized resource. Flexible, team-based models of care that give a bigger role to AAs can take the pressure off of anesthesiologists. “The big thing is making sure we’re doing this intelligently, intentionally, and safely,” said Orser.
Canadian Barriers
The efficient use of a limited workforce remains hampered in Canada because healthcare workers can provide care only in the province in which they are licensed. Medical societies are lobbying to reduce or remove this barrier. In addition, although the Canadian healthcare workforce is keen to work collaboratively, there is no established system of nationwide communication to share creative solutions.
As a result, provinces are largely working independently to address the shortage. Quebec employs a “hub-and-spoke” approach in which urban hospital systems sponsor rural hospitals and supply anesthesiology services. British Columbia and Ontario are focused on community building in remote areas so that FPAs feel less isolated. These efforts include not only mentorship, skill building, and networking programs but also support for finding schools for FPAs’ children and jobs for their spouses.
What About Nurse Anesthetists?
In the US, anesthesiology services in rural areas are largely provided by certified registered nurse anesthetists (CRNAs), and many have questioned why Canada has resisted taking the same approach.
Mike MacKinnon, DNP, FNP-C, a Canadian nurse who moved to the US to train as a CRNA and currently works in rural Arizona without the oversight of an anesthesiologist, would love to do the same in Nova Scotia, where he was born and where his family still resides.
“I don’t think Canada has as much of an anesthesia problem as it has a workforce model problem,” he told Medscape News Canada. “A lot of that is trade protectionism.” He pointed to the rigorous 3-year training in anesthesia that CRNAs undergo (compared with 1 year for FPAs or AAs) and their solid safety record in the US.
But Fuda, Orser, and Alam are adamant that an “American solution” should not be imported to solve a “Canadian problem.” “We already have a nursing shortage in Canada,” said Fuda. “So if you train some of the nurses [to deliver anesthesia], you’re cutting even more nurses [from areas of higher need].”
Perhaps the biggest barrier is the need to develop training and licensing programs for CRNAs when it is already a struggle to fulfill the needs of current anesthesiology, FPA, and AA programs. It would be far better to maximize the potential of existing AAs and FPAs than to introduce a new stream, argued Alam and Orser.
Fuda and Orser are optimistic about the future of anesthesiology care in Canada. Since the beginning of the COVID pandemic, said Fuda, “I can safely say that things did get better. So I’m very optimistic that within just a few years, things are probably going to get better to the point where we might go back to not having any shortage at all.”