Author: Megan Rolfzen, MD
The Daily Dose
Anesthesiology currently faces a growing workforce challenge that extends beyond filling residency positions. Although anesthesiology residency remains competitive, fewer graduates are pursuing subspecialty fellowships, academic careers, and physician-scientist pathways.
A session presented at the 2026 IARS and SOCCA Annual Meeting examined the financial, cultural, and organizational barriers contributing to this decline. The speakers emphasized that preserving subspecialty expertise and scientific discovery will require more than recruiting additional trainees. Academic departments must fundamentally redesign how they support, mentor, and reward those pursuing advanced clinical training and research careers.
Declining Interest in Subspecialty Fellowships
Allison Dalton, MD, discussed the increasing number of unfilled positions among the six major ACGME-accredited anesthesiology subspecialties:
• Adult cardiothoracic anesthesiology
• Critical care medicine
• Obstetric anesthesiology
• Pain medicine
• Pediatric anesthesiology
• Regional anesthesiology
Approximately 1,250 fellowship positions are available each year. Filling all of them would require roughly 65% to 75% of graduating anesthesiology residents to pursue fellowship training, which is unrealistic under current conditions.
Adult cardiothoracic anesthesiology has remained relatively resilient, but pain medicine has experienced a concerning decline in anesthesia-trained applicants between 2019 and 2024. A widening gender disparity has also emerged within some fellowship pathways.
Financial Pressures Affect Fellowship Decisions
Financial concerns are among the most important reasons residents may choose employment rather than an additional year of training.
The average medical student now graduates with approximately $250,000 in educational debt. At the same time, anesthesiology practices frequently offer substantial salaries and signing bonuses to physicians entering the workforce immediately after residency. The average reported signing bonus for an anesthesiologist was $46,502.
For residents carrying significant debt, a fellowship year may represent a considerable opportunity cost. Trainees must compare a fellowship salary with the much higher compensation available through immediate clinical employment.
Potential solutions include:
• Supplementing fellowship salaries
• Providing signing bonuses or loan-repayment assistance
• Developing flexible or nontraditional fellowship pathways
• Offering senior supervisory rotations with greater independence
• Demonstrating the long-term professional value of subspecialization
• Connecting residents with subspecialty mentors earlier in training
Mentorship may be especially important. Residents are more likely to pursue advanced training when they understand how subspecialization can improve career flexibility, leadership opportunities, professional satisfaction, and long-term expertise.
The Erosion of the Physician-Scientist Pathway
Peter Allan Klock, MD, addressed the declining number of anesthesiologists pursuing research careers.
Preliminary survey findings regarding changes in federal research priorities suggested worsening job satisfaction among academic anesthesiologists, loss of research personnel, and increasing pressure to shift toward clinical or industry-supported work.
Approximately one in five surveyed members of the American Society of Anesthesiologists and the Association of University Anesthesiologists reported plans to reduce or completely leave research.
This decline threatens the specialty’s ability to generate its own evidence, develop new treatments, and answer important questions involving perioperative medicine, pain, critical care, and patient safety.
The Long-Term Value of Early Research Investment
Evidence suggests that supporting young investigators can produce substantial long-term benefits.
A previous study found that 79% of Foundation for Anesthesia Education and Research grant recipients remained in academic anesthesiology. Collectively, these researchers later obtained more than $448 million in National Institutes of Health funding.
However, anesthesia research funding has become increasingly concentrated. In 2025, five institutions received approximately 41% of the roughly $250 million awarded to anesthesia departments in the United States.
This concentration makes it more difficult for smaller or less-established departments to develop sustainable research programs.
Building Research Infrastructure Into Training
Academic departments may need to make research support a permanent part of their infrastructure rather than expecting individual investigators to build programs independently.
Recommended investments include:
• Dedicated biostatistical support
• Departmental seed-grant programs
• Protected research time
• Research coordinators and technical personnel
• Formal physician-scientist mentoring
• Grant-writing assistance
• Structured research pathways during residency
Programs such as Duke University’s Academic Career Enrichment Scholars and Washington University’s Academic Scholars Advancement Program demonstrate how research training can be incorporated directly into residency.
Early exposure may help residents view research as a realistic career pathway rather than an additional obligation that competes with clinical training.
A Workforce Problem Decades in the Making
Jeffrey Berger, MD, MBA, explained that the current shortage of subspecialists and academic anesthesiologists did not develop suddenly.
The 1997 federal cap on graduate medical education funding limited residency growth. Policies and workforce predictions from the 1990s also discouraged specialization based on concerns that the country might produce too many specialists.
Additional barriers now include administrative burdens, immigration and visa expenses, research-funding uncertainty, and employment models that may treat physicians primarily as interchangeable clinical labor.
At the same time, large educational debts and attractive private-practice compensation have changed how residents evaluate career options.
Protecting the Academic Mission
The academic mission cannot survive solely through appeals to tradition or professional obligation. Departments must provide practical incentives and sustainable career structures.
Necessary reforms may include:
• Competitive fellowship compensation
• Meaningful protected academic time
• Recognition of teaching and scholarship in promotion decisions
• Reduced administrative burdens
• Improved research infrastructure
• Flexible fellowship and research pathways
• Stronger mentorship beginning during residency
• Financial rewards for advanced expertise and academic contributions
Without these changes, fewer physicians may be willing to accept the financial and professional sacrifices associated with subspecialty or research careers.
The Future of the Specialty
The decline in fellowship participation and physician-scientist development could eventually affect patient care. Anesthesiology requires clinicians with advanced expertise in cardiac anesthesia, critical care, pain medicine, obstetrics, pediatrics, regional anesthesia, and perioperative medicine.
The specialty also needs investigators capable of producing independent evidence rather than relying entirely on research generated by other medical disciplines or commercial organizations.
Reengineering the pipeline will require cultural, structural, and financial change. Academic departments must protect research time, reward scholarship, improve fellowship compensation, and demonstrate that subspecialization provides lasting professional value.
The message from the session was clear: inaction will accelerate the decline. Preserving anesthesiology’s academic and subspecialty missions is essential to ensuring that the specialty continues to provide sophisticated, evidence-based patient care.
Thank you to The Daily Dose and the International Anesthesia Research Society for allowing us to summarize this important session.