Safe and efficient anesthesia staff allocation is an integral part of perioperative care. Hospitals and health systems use different strategies and staffing models that may include anesthesiologists only or anesthesiologists with resident physicians, extender trainees, and nonanesthesiologist providers, such as certified registered nurse anesthetists (CRNAs), or certified anesthesiologist assistants (CAAs). Factors that may determine anesthesia staffing model selection include patient volume, case complexity, scheduling, availability, state/local laws, institutional policies, and cost. According to the latest anesthesia workforce trends report published monthly by the ASA’s Center for Anesthesia Workforce Studies (CAWS), there are nearly 43,000 clinically active anesthesiologists (determined by Medicare billing data) in the United States (April 2024). The number of clinically active CRNAs is 51,000, and the total number of CAAs is around 3,900 (asamonitor.pub/3xInZNZ). In addition, anesthesiology residents are an important part of the clinical workforce. There are 178 anesthesiology residency training programs nationwide offering a total of 2,000 residency spots for each year of training (asamonitor.pub/3VK46y6).

Evaluating different staffing models for efficiency is important for determining current and future needs for a hospital or health system as well as financial incentives for the workforce. The evaluation of efficiency of different anesthesia care models is difficult (Anesth Analg 2003;96:1109-13). The anesthesia care team model depends on practice type, namely academic, private, corporate (national groups), and hospital-employed. Though clinical efficiency is often at the forefront when considering staffing models, it is not the only determinant of success. Consider, for example, the academic setting, where factors such as educational, training, and research activities may influence overall production (Anesth Analg 2008;107:1981-8; J Clin Anesth 2021;71:110194). In an academic setting, one anesthesiologist can supervise only two extenders when trainees (residents/fellows) are involved. On the other hand, while supervising CRNAs or CAAs, the ratio is often increased, based upon a desire to use either a direction or supervisory model. Additionally, supervision needs can change with the complexity of the cases and intraoperative critical events, namely airway issues, bleeding, or other emergent situations, which necessitates the ability to be flexible (Anesthesiology 2012;116:683-91).

In contrast, for-profit anesthesia groups adopt and adapt care models ranging from physician-only care to CRNA-only care and in between. These for-profit groups exist and thrive because they can provide much-needed services to hospitals and health care facilities, making profit in return. Numerous for-profit groups provide care in multiple states, employ thousands of clinicians, and utilize the entire range of staffing models (asamonitor.pub/45Gk4Om). These “for-profit” anesthesia groups may adapt staffing models over time to maximize profit. Anesthesia billing changes significantly with the staffing model, utilizing different coding modifiers (e.g., QK, QY) to indicate coverage levels. However, it is important to note that staffing does not always change to maximize profit and may instead be dictated by local culture, preferences, or commitments to a group or facility prior to merger or acquisition.

Case complexity, acuity, and staffing requirements warrant different staffing models. In tertiary care hospitals, anesthesia services are often required at different locations in the facility. This may include coverage for open heart surgery, neonatal surgery, anesthesia services in GI suites, and labor and delivery suites. Coverage levels often vary for different times of the day (Anesth Analg 2003;96:1109-13). Anesthesia staff providing care in some clinical scenarios may require skills – including intraoperative TEE or the ability to do peripheral nerve blocks – that will affect the staffing model. In this situation, the productivity and efficiency determination of anesthesiologists providing specialized care can be challenging.

Efficient utilization of operating suites can present a different set of challenges. Hospitals assign block time to the surgical staff based on their patient volume and convenience. If the scheduled number of patients changes on a certain day, it will result in assignment of anesthesia coverage for a location that lacks available procedural workload. On the other hand, if a location has booked more patients than the available anesthesia coverage, it may result in cancelation/rescheduling of surgical cases, causing patient dissatisfaction. Therefore, surgical site optimization is an important determinant of cost-effective anesthesia coverage. This under- or overutilization of the operating suite can occur because of inaccurate estimation of surgical durations by the surgery team and patient factors that include delayed wake-up or intraoperative events (Heath Care Manag Sci 2017;20:115-28).

Is anesthesia care better or safer in a particular staffing model? Research has shown that physician-guided care prevents excess deaths in the perioperative period and has other significant benefits such as decreasing the rates of undesired disposition following ambulatory surgery (Cochrane Database Syst Rev 2014;2014:CD010357). These facts often lead decision-makers to insist on physician-led care, as advocated not only by ASA but also the World Health Organization, in conjunction with the World Federation of Societies of Anaesthesiologists.

Five states allow nurse anesthetist-only care. While 25 states have opted out of the CMS requirement for physician supervision of nurse anesthetists, those states’ laws were not impacted that require physician oversight or involvement. Additionally, institutional and facility policies may restrict nurse anesthetist-only anesthesia through their own internal policies, safety preferences, facility culture, and past experiences. Also, there is some evidence that hiring anesthesiologists in rural areas can be difficult due to several factors (Cochrane Database Syst Rev 2014;2014:CD010357).

A reason for this may include that smaller rural hospitals are disincentivized from hiring anesthesiologists due to the federal payment program known as Rural Pass-Through. That program allows for an enhanced payment under Medicare Part A for the services of certain anesthesia providers – nurse anesthetists and anesthesiologist assistants – but not anesthesiologists. Pending federal legislation H.R. 5256, the Medicare Access to Rural Anesthesiology Act would open the program to anesthesiologists, giving them equal standing.

Mills et al. conducted a study employing semi-structured interviews of hospital administrators aimed at defining their perceptions of the safety, quality, and cost effectiveness of using different staffing models. Their findings showed that rural facilities utilized predominantly CRNA models. Staffing choice was made based on location, surgeon’s choice, and institutional factors, while anesthetic and quality and safety did not influence (or was not considered in) decision-making. A surgeon’s comfort level with the anesthesia coverage model in question has a major influence, because “it is the surgeon’s patient” and the surgeon makes the choice to bring surgical volume to one place or another, hence their influence. Administrators interviewed usually were not very familiar with anesthesia payments models (APMs). Also, most facilities in this study reported the “contracted groups over hospital/surgical site employed” model as the preferred system (Cochrane Database Syst Rev 2014;2014:CD010357).

Every hospital and surgical team has a diverse background and circumstances. Institutional norms and culture are determined by the clinician’s past experiences and training, the administration’s experience, and the financial circumstances of the hospital/institution. Institutional and personnel preferences include comfort and desire to work with or avoid working with physician extenders (CRNAs/CAAs), need for in-house coverage for trauma/OB 24/7, representation of anesthesiologists on hospital committees, and desire to work with surgical teams/providers in a certain perioperative care model (e.g., enhanced recovery after surgery (ERAS) protocols). For example, when implementing ERAS protocols, anesthesiologists play a leading role, which has shown to improve patient experience by shortening length of stay, decreasing costs, and preventing perioperative complications.

Another important factor in determining anesthesia staffing model is geographic location. There is some evidence that it is difficult to hire anesthesiologists in rural areas, while other anesthesia providers might be relatively easier to hire in rural hospitals. Availability of physician extenders is also determined by geographical location. CRNAs can be licensed in all 50 U.S. states. At present, 17 states and the District of Columbia have laws for CAA licensure, and they can work under physician license in four other states (Kansas, Michigan, Pennsylvania, and Texas). CAAs are also able to work in the Veterans Affairs (VA) health care systems, while the remaining 28 states have yet to authorize their practice. Legislation in those states may alleviate the workforce burden and improve availability of anesthesia services.

The factors that drive anesthesia staffing models at individual institutions vary greatly between provider groups. It may be difficult to perform quality research in this field. A range of factors influence the choice, including case load, complexity, specialty care (cardiac, pediatrics, etc.), institutional culture, geographic location, and, of course, the mighty dollar.

On April 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released a memorandum revising its guidelines on obtaining informed consent for invasive procedures and sensitive examinations when individuals other than the primary physician are involved. To remain compliant, anesthesiology departments and their representatives, such as attending anesthesiologists, must now inform patients and their family members when residents, or medical, nurse anesthetist, or anesthesiologist assistant students, will be performing invasive procedures or other important tasks related to surgery. Such procedures and tasks include endotracheal intubation or other aspects of airway management, invasive line placement, and administration of anesthesia, both general and regional (asamonitor.pub/3xDjm88).

This revision comes after several mainstream media reports highlighted the practice of subjecting patients to sensitive examinations by various learners without their consent, with emphasis on examinations performed while the patient was under anesthesia (asamonitor.pub/45Lpt6H). Even prior to such reports, medical literature supported abandoning this practice in exchange for a more transparent one (Obstet Gynecol 2019;134:1298-02).

Mastery of the technical skills of airway management and invasive line and regional block placement is essential for all anesthesia trainees. At the end of training, our learners must confidently manage routine airways in daily practice as well as in emergent situations where swift, decisive action is required. To achieve this goal, trainees need hands-on experience with a wide variety of patients, under appropriately supervised conditions. While the level of supervision may change as a trainee’s technical skills, confidence, and decision-making abilities develop, it is never wholly eliminated. This balance maintains a standard of patient safety and promotes an effective learning environment.

While such practical experience is a crucial component of anesthesia training, it is equally important to uphold patient autonomy and self-determination, as this new CMS requirement emphasizes. Patients must be informed about the medical care they receive, in compliance with informed consent standards; they subsequently are entitled to make decisions about the proposed procedures and treatments. The shared information must include risks and benefits of trainee participation in their care. Patients then elect whether to allow such participation, including performance of invasive procedures like line and block placement. Respecting patient autonomy is a fundamental principle of medical ethics that has evolved over recent decades, from the patient serving as a collaborator in decision-making with the medical team to acting as the leader. Anesthesiologists are obligated to assist patients in this process by providing evidence-based answers to questions and acknowledging uncertainty where it exists (Anaesthesia 2021;76:1442-5).

To comply with the new CMS guidelines, uphold patient autonomy, and retain a learning environment that supports the needs of our trainees, anesthesiologists should clearly communicate several key details in the informed consent process regarding trainee participation in invasive procedures and anesthesia administration. They should indicate the learner’s degree of experience and the level of supervision provided throughout the procedure. Such disclosure allows the anesthesiologist to assess the patient’s comfort with the trainee’s involvement. Additional patient questions or concerns may arise; providing adequate answers is not only part of the informed consent process but also empowers the patient as a proponent of their own care while the anesthesiologist serves as an advocate for the trainee’s education. It may also be appropriate to discuss emergency protocols, assuring the patient that the anesthesiologist is prepared to immediately take over the procedure should any concerns arise. Such reassurance helps patients feel that their safety is of the highest priority. This reassurance reinforces patient autonomy as well as justice by ensuring that patients in comparable situations are treated similarly. In addition, the concepts of beneficence and nonmaleficence are also supported by enabling patient empowerment, preventing harm from occurring, and allowing for the best training opportunities for the next generation of anesthesia practitioners.

The performance of invasive procedures by anesthesia trainees is critical for developing competent anesthesiologists and other anesthesia professionals who can manage complex and emergent situations. However, this educational obligation must be carefully balanced with the ethical imperatives of patient autonomy, self-determination, justice, beneficence, and nonmaleficence. Incorporation of additional details regarding trainee involvement into the informed consent process strikes this balance, ensuring trainees continue to receive the necessary, practical experience, while respecting both the established medical-ethical and new CMS standards for informed consent.

A board-certified anesthesiologist with six years of clinical practice leaves in order to care for ailing parents. After a five-year hiatus, the physician wants to return to clinical practice. What are the options available?

It is not possible to know how many anesthesiologists are in a similar situation of seeking to return to clinical practice after taking a career hiatus. The reasons for career hiatus vary tremendously, ranging from family obligations (e.g., raising children or caring for a family member) to recovering from a personal illness (physical or mental). Because clinical competency requires constant maintenance of technical and critical decision-making skills, particularly during rapidly changing clinical situations, anesthesiologists are hesitant to take a hiatus when it is unclear how to reenter clinical work. For the specialty, losing highly trained physicians from the workforce with no reentry path is even more detrimental to the current workforce shortage. Anesthesiologists risk burnout, wellness issues, and compromised patient care when they continue to work despite stressful personal situations. They fear an extended hiatus will prevent their eventual return to practice. However, it is important to note that there are options available to allow for reentry, providing a safety net for the individual anesthesiologist. This support is not only beneficial to the individual but also to the specialty.

Although there are several options, in this article, we highlight two different reentry processes with which each of us is involved. The first one describes an external program available for any physician. The second describes an example of how anesthesiologists can contact their residency program to do a “reentry” fellowship.

The first example is called KSTAR (Knowledge, Skills, Training, Assessment, and Research), which is based out of Texas A&M Health in College Station, Texas (asamonitor.pub/4cIKORe). KSTAR is an internationally recognized program that provides comprehensive assessments, evaluations, return to board eligibility, and reentry programs for physicians. KSTAR also has a three-month (or longer when needed) reentry mini-residency for qualifying physicians. The University of Texas Medical Branch is the main site for the reentry mini-residency, and my (AEA) department is the starting point for anesthesiologists going through KSTAR. Prior to KSTAR contacting our department, the anesthesiologist applies and goes through the assessment and evaluation process during a two-day, on-site program. The assessment may include, but is not limited to, standardized patient encounters, record review, NBME multiple-choice testing, cognitive screening, and physician discussions and interviews. The application process includes background checks, license review, and CME reviews. After successfully completing the assessment program, the anesthesiologist can apply for reentry training with UTMB. Through KSTAR, the anesthesiologist will purchase medical liability insurance via the Texas Medical Liability Trust. At UTMB, the anesthesiologist works under the supervision of anesthesiology faculty, similar to a resident. Rotations and experiences are individualized to meet the goals of the anesthesiologist. During the three-month period, the anesthesiologist continues to meet weekly with the KSTAR medical director. The program requires a fee for the assessment ($12,600), cost of the mini-residency ($13,500), liability insurance, and living expenses in Galveston. The anesthesiologist will not receive a salary from UTMB.

In some circumstances, a second pathway may be the residency program where they previously worked or trained. Training programs amendable to the concept may require interviews, references, and active maintenance of medical board licensure. The Ohio State University, for example, has created a fellowship for such purposes, but it limits consideration to former trainees or faculty who are also candidates for jobs afterward. Since the program is overseen by the graduate medical education (GME) office, the anesthesiologist is employed as a trainee for six months, receives medical liability insurance like other clinical subspecialty fellows, and is later considered for employment to help facilitate the final transition to practice. The clinical experience is individualized, includes lectures and simulation with residents, and clinical oversight progresses toward autonomy over the six-month period. Programs wishing to consider creating such a program should work closely with their GME office and credentialing boards. It is also important to note that while a completion certificate is provided, it does not imply certification of competency.

In our experience, anesthesiologists commonly face several challenges during reentry. The first is overcoming the hurdle of self-doubt about returning to clinical practice. For most, the basic skills of anesthesiology come back quickly, including technical skills like I.V. placement and bag/mask, intubation, as well as nontechnical skills like communication, evaluating the patient, and crisis management. The second challenge is technology. Since the introduction of the electronic medical record (EMR) in the last decade, some anesthesiologists need to learn how to use modern forms of EMR documentation. Again, despite the hesitancy, most reentry anesthesiologists quickly adapt to this new technology. Another challenge is the expansive use of ultrasound for vascular access, regional anesthesia, and point-of-care ultrasound (POCUS) diagnosis. Reentry anesthesiologists need this experience and would ideally be exposed to an ultrasound curriculum within the program. For the three-month reentry KSTAR program, experience is obtained in the third month, but often the reentry physician will work with our program to develop additional experience outside the required time. For a reentry fellowship, ultrasound experience can either be included as part of applicable rotations or as a separate experience.

Rob Steele, MD, FAAFP, former Medical Director of the KSTAR program, has over 20 years of experience in physician clinical performance evaluation and remedial programs. In a recent podcast about the reentry physician and the challenges of coming back to practice, Dr. Steele provided insights and advice to physicians considering a clinical hiatus (doctorscrossing.com/episode165/). First, maintain an active medical license, take CME courses, keep your DEA certificate, and maintain your board certification. This facilitates more career options and reduces the likelihood of specific medical board requirements for retraining. Second, if there is a way to avoid completely stepping away from clinical practice by working part-time, returning to full practice could be easier. In his experience, having a hiatus of fewer than two years often allows a physician to return to practice without a major assessment or retraining. In the current workforce shortage, one should be able to find a “prn” position with a local group(s). Third, the anesthesiologist needs to understand the requirements for credentialing. Many facilities require peer evaluation of someone who has worked with the anesthesiologist in the last two years. Hence, even with an active license, the anesthesiologist who has been out of practice for more than two years may require some sort of supervised clinical practice to fulfill credentialing requirements.

What is an arbitration provision and how does arbitration differ from litigation?

Arbitration is a form of alternative dispute resolution in which the parties agree to resolve any disputes using one or more arbitrators. Arbitration provisions typically are mandatory – the sole method to resolve disputes, and the parties may not file suit in state or federal court.

Arbitration proceedings differ from court proceedings in several important ways:

• First, the decision-maker is the arbitrator (or several arbitrators), not a jury. That means that a single person, or typically no more than three individuals, decides the dispute. In contrast, a jury, drawn from the public, may be more sympathetic to a physician employee than arbitrators, who often are lawyers or retired judges.
• Second, arbitration is confidential. Although a physician may want the public to know about a dispute (e.g., discrimination, wrongful termination, or challenge to a noncompete), an arbitration proceeding frustrates that goal by keeping the dispute confidential. Privacy is a key reason an employer may require arbitration.
• Third, arbitration adds cost to dispute resolution; the parties must pay the sponsoring arbitration service and compensate the arbitrator(s) for their time, including preparation and decision-writing time. An individual physician may be less willing than the employer to pay the costs of arbitration. The expense of arbitration can serve as a disincentive to pursue a claim.
• Fourth, unlike a court, arbitrators lack authority to enforce orders.

How does an arbitration provision limit an employee’s or independent contractor’s rights?

Each of the differences discussed above is a limitation of rights that court proceedings would offer, including the rights to 1) a public record of the dispute and public proceedings and 2) a jury trial, as well as 3) the ability to pursue the case without the expense of the court itself (except in instances when costs are assessed) and the judge’s time. Other limitations depend largely on how the arbitration provision is worded. Importantly, a mandatory arbitration provision does not necessarily limit an employee physician’s right to file a charge (e.g., for discrimination) with the Equal Employment Opportunity Commission, though the agreement to arbitrate is binding on the parties.

A mandatory arbitration clause may limit an employee’s rights by preventing class action claims. A class action can be an efficient way to proceed for a group of individuals who allege the same grievance. Loss of that right means that an individual physician alone will bear the cost of arbitration rather than being able to share the costs with others. It is important to review an arbitration provision carefully to identify any other restrictions the provision imposes and to review the sponsoring organization’s procedural rules. Discovery (the information gathering process) may be more limited in mandatory arbitration than in a court proceeding. For example, in an arbitration proceeding, a physician may not have a right to take depositions of knowledgeable persons on the other side of the dispute.

What expenses are involved?

The primary expenses of an arbitration proceeding are the costs of the arbitrator(s) as well as the fees of the sponsoring organization. The mandatory arbitration clause usually will identify the sponsoring organization and number of arbitrators. A sponsoring organization’s fees may depend on such factors as 1) number of arbitrators, 2) number of arbitrator candidates the parties request, and 3) whether the request for arbitration (in employment disputes) is filed by an individual or the company. For example, AAA filing fees (asamonitor.pub/4ccNciG) for single arbitrator employment arbitration matters range from $350 (if filed by an individual; the company must pay $2,100, as well as a case management fee of $750) to $2,450 (if filed by the company/employer, along with a $750 case management fee). The fee is higher for three-arbitrator panels. AHLA rules (asamonitor.pub/4eFk84T) provide for costs from $900 (parties select an arbitrator) to $1,700 (list of 15 candidates) for assistance in providing names of possible arbitrators. Those rules also may require the employer to bear most of arbitration cost, at least initially. One arbitration organization charges a case management fee that is a percentage of all arbitrator professional fees, rather than a flat fee (jamsadr.com/arbitration-fees).

The arbitrators often charge an hourly rate (with a daily minimum) plus expenses. Arbitrators charge for time spent on prehearing motions and matters, preparing for hearings, reviewing the parties’ filings, hearing days, and writing an opinion. These fees are in addition to each party’s attorneys’ fees. Arbitration agreements often address who pays for the cost of the arbitration proceeding. Common approaches are:

1. The parties share the arbitration costs 50-50. This approach may be the most beneficial to an individual physician.
2. The party initiating the mandatory arbitration pays the costs. If a physician must arbitrate any dispute under an employment or other agreement (e.g., operating or shareholder agreement), the physician will be faced with additional costs to seek relief, which may (and may be intended to) have a chilling effect on the physician’s willingness to seek review of a dispute.
3. The non-prevailing party pays all costs. Under this approach, the non-prevailing party is responsible for all costs of the arbitration. Often, the non-prevailing party also must pay the prevailing party’s legal fees. This approach similarly may serve as a disincentive to seek review of a claim, as an employee physician risks being responsible for potentially substantial costs if the physician does not prevail.

How will a physician know how to select an arbitrator?

Unlike a court proceeding, where a judge is assigned and the litigants have no say (absent unusual circumstances, e.g., a claimed conflict of interest on the part of the judge), the parties select the decision-makers in arbitration. In arbitration, the parties often have little information, although a physician’s counsel may be familiar with particular arbitrators or have access to evaluations of an arbitrator’s performance.

What rules apply to arbitration proceedings and how can the choice of rules affect the proceeding?

The arbitration agreement usually specifies the sponsoring organization for any arbitration, and it may specify the procedural rules that apply to the proceeding. The sponsoring organization’s rules will affect such matters as the required experience and/or training for arbitrator candidates and the time frame in which the arbitrator(s) must decide a case. Procedural rules will specify, among other things, the type of evidence that may be presented (e.g., whether hearsay evidence is permitted).

An anesthesiologist likely wants an arbitrator with knowledge of the health care industry and common issues in the industry. Note that arbitrator candidates with relevant experience may represent health systems and may not be familiar with a physician’s perspective.

Is arbitration a faster process than litigation?

Generally, arbitration may be faster than litigation, but it depends on the court dockets as well as the complexity of the dispute, applicable rules, and whether the parties push the arbitrator to resolve the dispute.

Can arbitration work in a physician’s interest?

In some circumstances, yes. For example, the physician may prefer the nonpublic nature of an arbitration proceeding if the physician is defending against a claim that the physician does not want to be a matter of public record. The potential for faster resolution of a dispute may also be in a physician’s interest.

May a physician appeal an arbitration decision?

If arbitration is binding, the decision of the arbitrator(s) is final and may not be appealed. Arbitration agreements often require binding arbitration with no appeal rights.

How does mediation differ from arbitration?

Mediation is a dispute resolution process in which a selected third party (mediator) assists the parties to resolve their dispute. Unlike arbitration, the mediator does not decide the dispute. Mediation can be a useful tool to try to resolve a dispute prior to arbitration. Mediation is the preferred route in the context of a continuing relationship (e.g., employment), as arbitration (like litigation) can irreparably harm a relationship.

As with many provisions in a contract, a mandatory arbitration clause merits close attention to understand the risks and costs that the provision entails. Mediation is often a better starting point to resolve a dispute.

Despite the use of neuromuscular blocking drugs in anesthesia practice being routine since at least 1942, there has only recently been a focus on ensuring that patients do not remain paralyzed at the conclusion of an anesthetic. To combat partial paralysis after anesthesia, quantitative twitch monitoring should be performed – but what is the most effective technique in the clinical setting? Andrew Bowdle, MD, PhD, FASE, Professor of Anesthesiology and Pharmaceutics, Laura Cheney Professor in Anesthesia Patient Safety, Department of Anesthesiology, University of Washington, weighs in on electromyography versus acceleromyography for twitch monitoring.