At state and national meetings that I attend, the number-one issue is workforce, whether it is nursing, physicians, or other hospital staff. So, why the shortages and what can we, as a profession, do about it?
ASA has examined workforce issues in the past with studies by the RAND Corporation (asamonitor.pub/3C4YuWu; asamonitor.pub/3D7D4WV). These extensive studies used multiple methodologies to determine whether an anesthesia workforce surplus or shortage exists, including a demand-based analysis and an economic approach. According to the 2009 study, we needed to increase the supply of anesthesiologists by 3,800 full-time equivalents (FTEs) to meet the demand, and nurse anesthetists would need to increase by 1,282 (that is with a clinical work week of 49 hours for anesthesiologists and 37 for nurse anesthetists, which was the average in the survey data). At that time, 54.1% of states in the U.S. had a shortage, and the average state would need 10% more anesthesiologists. By 2013, we had closed the gap in shortages of anesthesiologists by an estimated 2,000, but RAND was projecting shortages accelerating again in 2017 to about 3,000 because of the retiring baby boomers. We don’t need another study to tell us we have a supply/demand imbalance. What we need are solutions.
ASA Workforce Summit
I chaired an Anesthesia Workforce Summit in June 2022 where a cross-section of representatives from medical societies, academic institutions, certifying organizations, hospitals, hospital networks, and physician practices (small, medium, and large) gathered to examine the current data from the ASA Center for Anesthesia Workforce Studies and propose some solutions. The workgroups that came out of this task force include New Training Paradigms, Harnessing the Workforce Potential, Staffing and Efficiency in the Operating Room, and Anesthesiologist Utilization, Non-Operating Room Anesthesia (NORA), and Sedation Models
The federal government, through the Centers for Medicare & Medicaid Services (CMS), is a major funder of graduate medical education (GME) positions. Unfortunately, this funding has been frozen since the 1997 Balanced Budget Act except for new programs or hospitals with rural designations. Although medical schools have grown, our GME slots have not grown commensurately. No wonder a physician shortage exists, and not just in anesthesiology!
On the good news front, our specialty is extremely popular as a choice for medical students (Figure 1). Last year, medical students matched at 99.6% with 1,973 PGY-1 and PGY-2 matches, which is a 120% increase since 1990! (ASA Monitor 2022;86:30–1). Compare this to less than 300 matching in 1996 when everyone thought there was going to be an oversupply of anesthesiologists. That small cohort in our demographics is still affecting our supply (Figure 2). The other thing of note – there were 2,888 applicants who wanted to match in anesthesiology in 2022 but didn’t! That is an opportunity you will read about from our New Training Paradigms workgroup.
The other issue contributing to the current shortage is part of the “Great Resignation” (asamonitor.pub/3S5bzEW). The profession saw four years of retirements in one year! Add to that the large numbers of baby boomers at or near retirement age and you see that we also have an attrition issue. A new generation of anesthesiologists who may want to work differently than the baby boomers of the past also affects the supply of FTEs.
How do we keep everyone in the workforce? The key here is flexibility. Does the practice offer job sharing, flexible hours, night-time only, or daytime only? The article in this issue on “Harnessing the Workforce Potential” gives some solutions that groups are trying and finding some success with. These solutions in scheduling and governance are great recruitment and retention tools.
The supply of anesthesia professionals has increased 26.3% compared with 2.8% for surgeons and proceduralists since 2014 (Center for Anesthesia Workforce Studies, Thomas Miller, PhD, ASA Workforce Summit DATABOOK), but the demand continues to outstrip supply. The demand comes on many fronts: more proceduralists don’t want to sedate their own patients either because of knowledge and experience gaps or because they have found that anesthesia professionals can offer them efficiency with a high safety record. Medicare-certified ambulatory surgery centers have proliferated since 2014, with an 11% increase (Center for Anesthesia Workforce Studies, Thomas Miller, PhD, ASA Workforce Summit DATABOOK), and hospitals continue to add NORA locations in far-away locations. Add to that the other inefficiencies of surgeons all wanting a 7:30 a.m. start time but who may only have a half day of work. What is efficient for the surgeon may not be efficient for the anesthesiology department or OR staff. COVID has not helped hospital efficiencies with last-minute cancellations, either. The article “Staffing and Efficiency in the OR” discusses the need for aligning all resources in these times of shortages.
“Anesthesiology Oversight for Procedural Sedation” on page 42 describes the responsibility of the director of anesthesia services, by CMS and the accrediting organizations, to oversee sedation services in your hospital. Many will look on this as an onerous responsibility, but this is also an opportunity for a leader in an anesthesiology department to work with hospital administration to ensure that patients are sedated safely with efficient use of resources. I have worked in a children’s hospital in south Texas, a designated Health Professional Shortage Area, for many years. We have had to learn how to take care of children safely by working with our physician colleagues and nursing staff, as we don’t possess the resources to have an anesthesia professional personally deliver sedation to every child needing a bone marrow biopsy or setting a fracture in the emergency department.
We are also seeing demand for sedated MRIs and specialized hearing tests in infants and young children. Many of our pediatric specialist physicians who have just finished their fellowships have not had the training and experience in doing their own sedation (unlike their older colleagues) with trained nursing staff. Our anesthesia leaders have created the extra education and training (with skills testing in our simulation lab and ORs) to teach our physician colleagues how to provide sedation safely in an oncology clinic, cardiology clinic (sedated echocardiograms), or emergency department. In addition, the anesthesiology department has also provided special training to the nursing staff involved in these procedures. All ASA standards are met for NPO status, pre-sedation evaluation, monitoring, and documentation. The hospital quality committee reviews all documentation and any untoward events monthly.
Because of the increasing waitlists for other nonpainful studies requiring sedation in children (like the auditory brainstem response exams), the anesthesiology department has also begun to use our pediatric intensivists (who are part of one anesthesiology and critical care department). Not all these services are covered by Texas Medicaid if you are not billing as an anesthesia professional. However, the hospital can recover the costs of providing that care with the facility payments, and children are able to get needed studies done in a timelier manner. These models of care, where you may not receive professional payments, require a negotiation with hospital administration, especially your chief financial officer, to get the buy-in for the extra costs involved in directly supporting this staffing, both physician and nursing.
The Pediatric Sedation Research Consortium has published data on the high level of safety that can be obtained in various models of care (Pediatr Crit Care Med 2016;17:1109-16). In 22,645 procedures performed with sedation using ketamine, three children suffered an arrest due to laryngospasm (all in radiology departments) who were appropriately managed with no long-term sequelae. These included high-risk infants and children. Sedation is a high-risk area that requires the oversight of anesthesiologists to ensure patient safety.
Anesthesiology is at an inflection point. Some worry that this is the perfect storm, but I think this is the perfect opportunity for us to leverage our expertise to hospitals to improve efficiency, patient safety, and workplace culture. Anesthesiology leaders need to have honest conversations with hospital administrators and their physician colleagues to find solutions that will find the win-wins. At the same time, we need to harness the desire of so many graduating medical students who want to become anesthesiologists. This includes efforts to increase residency opportunities to Americans going to foreign medical schools by facilitating U.S. accreditation of these schools (sites.ed.gov/ncfmea/). Although I am in a freestanding children’s hospital, we have provided pediatric anesthesia training for decades to residents in the military and other academic institutions in Texas. Working with residents is rewarding, helps with OR staffing, and really keeps all of us on our toes. It is also an economically viable model. I would encourage private practices to consider opening their doors, either creating their own residencies or partnering with other academic institutions to expand residency programs through private funding, until we can get more federal funding for expansion. This is the time to leverage the respect we have for our profession to increase our workforce and improve our relationships with hospital administrators. Carpe diem!