Closing the Chasm: Understanding and Addressing the Anesthesia Workforce Supply and Demand Imbalance

The healthcare workforce is susceptible to disequilibrium, which makes predictions challenging. However, modeling provides a framework, albeit imperfect, in combination with subject matter expertise to develop strategies that address future workforce challenges. Over the past three decades, modeling has predicted a gamut of workforce scenarios, from labor excess to labor shortages in anesthesia. 

Before the pandemic, the workforce was characterized by a slight labor shortage with regional maldistribution. The anesthesia workforce grew by approximately 18% between 2018 and 2023, while surgical specialists grew by 3.0%, and the number of specialists associated with non–operating room procedures grew by 26%. 

After brief decreases in surgical/procedural services during the heights of the COVID-19 pandemic, healthcare systems experienced a surge in demand that put additional stress on an already fragile workforce, resulting in a period of critical scarcity and financial instability, hampering the ability of healthcare systems to provide services. Before the pandemic, 35% of facilities reported an anesthesia staffing shortage.  Two years after the pandemic, the percentage of facilities with a staffing shortage doubled to an astounding 78%.  The pandemic accelerated the maturation of underlying issues of supply and demand (fig. 1) resulting in a dangerous spiral of work intensity and stress, unsustainable workloads, and retirements from clinical practice. The consequences of this “dangerous spiral” compromised healthcare access, quality, and safety and produced the healthcare crisis we are currently experiencing. 

The symptoms of a labor shortage of anesthesia professionals include increases in job postings, increases in compensation and signing bonuses; numerous commentaries by medical societies and physician leadership sounding the alarm about clinician shortages via traditional and social media and non–peer-reviewed literature; increased work hours; increased clinician burnout and attrition; transition to and use of contract and temporary workers; unplanned changes in staffing models for anesthesia services; and disruptions to the scheduling of surgery and procedures. However, even when the evidence of a workforce supply–demand imbalance seems substantial, there is no generally accepted formula to quantify the imbalance. 

In consumer markets, price is the mechanism by which a balance between supply and demand is achieved, and in most consumer markets, price and supply can adjust relatively quickly. This is also true in many labor markets, with compensation serving as the mediator of supply and demand. However, in professional and highly skilled labor markets such as the anesthesia workforce, short-term “market clearing” (a state where neither a labor shortage nor surplus occurs) is more complex, because neither supply nor compensation can adjust fast enough to ease the pressures resulting from a workforce imbalance. The challenges of market clearing as a solution for the labor shortage we are currently experiencing result from several factors, including the following:

• Regulation of training positions and a long lead time inherent in training new professionals hinder the ability to rapidly increase the number of clinicians entering the workforce.
• Monopoly power (i.e., limited employment options) may exist in local healthcare markets, limiting the ability for wages to adjust appropriately to demand shocks.
• Wages are “sticky” as a result of long-term employment contracts.
• Many of the payments to clinicians are fixed, based on government price setting or commercial contracts and may cause wages to be rigid (not responsive to demand).
• Specialization within anesthesia services with relatively low clinician-to-population ratios further hinders appropriate and timely adjustments to the workforce supply.

The healthcare workforce supply–demand imbalance is not isolated to anesthesia. Hospitals have emerged from the pandemic facing unprecedented financial pressures from staffing costs, especially in the high cost of locum tenens staff, which have reached crisis levels.  Workforce issues topped the list in the American College of Healthcare Executives 2023 annual survey of issues confronting hospitals for a second year in a row. Although concern regarding the shortage of physicians was noted by 71%, shortages of nurses and technicians were reported at 86% and 87%, respectively.  Further, labor costs are expected to have risen 6 to 10% in 2023, two or more times higher than inflation and higher than private industry at 4.1%.

Thus, anesthesia labor shortages must be viewed within the broader context affecting support and technical staff, nursing, and other physician categories. Reliable anesthesia staffing is essential to providing high-quality, safe, and timely procedural care, representing a major financial driver for health systems. However, anesthesia coverage agreements can be costly, and contracts are frequently sent for competitive bids, looking for immediate savings without fully appreciating adverse downstream consequences.

Distinct forces will strongly influence the anesthesia workforce supply–demand relationship. These forces include (1) the aging patient population, (2) the evolution of procedures and procedural areas, (3) the type and number of anesthesia clinicians entering the workforce, and (4) the changing generational preferences and attitudes.

In 2023, more than 58 million Americans were 65 yr of age or older, constituting 17.3% of the overall population. This cohort is expected to increase to approximately 90 million by 2050.  The older adult requires a disproportionate number of surgeries/procedures has more medical comorbidities, and is more vulnerable to complications. These facts suggest not only that the burden of anesthesia care will increase numerically but also that these patients will require a greater intensity of work and advanced skill sets.

The trend of movement of procedures that were hospital-based to outpatient settings and physician’s offices will continue. There will also continue to be a transition from invasive surgery to minimally invasive surgery or interventional procedures, driving a greater number of patients who were deemed excessively risky for surgery into lower-complexity procedures. In addition, noninvasive procedures will add to the increased demand for non–operating room anesthesia care, which is projected to exceed 50% of total anesthesia cases, with inherent scheduling challenges and inefficiencies. 

According to the National Plan and Provider Enumeration System in December of 2023, there were an estimated 138,000 anesthesia providers in the United States (fig. 2). This database includes all anesthesia professionals who have a National Provider Identifier number, including those who may not be currently in clinical practice. The Center for Medicare and Medicaid Services National Downloadable File has 97,000 anesthesia professionals who have billed Medicare in the last 6 to 12 months. Although the National Plan and Provider Enumeration System file may overestimate the number of practicing anesthesia professionals, the National Downloadable File underestimates because it does not include those who are billing Medicaid, private pay, etc. Using the National Downloadable File, the Center for Anesthesia Workforce Studies estimates that the clinically active professions are made up of about 43,500 anesthesiologists, 50,000 nurse anesthetists, and 3,200 anesthesiologist assistants. The Center for Anesthesia Workforce Studies also estimates that 5,200 anesthesia professionals entered the workforce from training programs in 2023, comprising roughly 1,900 anesthesiologists, 3,000 nurse anesthetists, and 300 anesthesiologist assistants.  The Center for Anesthesia Workforce Studies estimates that almost 4,800 anesthesia professionals left the workforce in 2022, including 2,500 anesthesiologists 2,200 nurse anesthetists, and 65 anesthesiologist assistants. Although there is a net increase in workforce supply, demand for the number of procedures, increasing medical complexity, and inefficiencies in scheduling will continue to strain resources.

The physician workforce is aging, with 57% of anesthesiologists 55 yr or older.  New generations, Generation Y and Z, are joining the workforce with different values than the Boomers they are replacing.  Generation Y and Z place a great value on work–life balance. In other words, even if the total number of physicians remains the same, the total clinical capacity will be reduced due to lower work hours per clinician. This hypothesis is supported by recent evidence documenting a reduction in physician work hours over the past two decades and a trend toward unionization.  Finally, noting an aging workforce, a recent article assessing selected academic practices reported anesthesiology as the highest specialty with “intent to leave” their current practice in the next 2 yr.

Historically, technology has had a transformational role in the development of our specialty, making it safer and more efficient.  Over the past 10 yr, with the advent of the electronic medical record, the anesthesia information management system, and the ability to collect and analyze large amounts of data, the focus has shifted from hardware to software to digital solutions. Monitoring systems are assisting clinicians through predictive and prescriptive analytics, and the delivery of anesthesia is expected to become more automated  Telemedicine allows clinicians and patients to interact digitally from multiple locations. Clinical decision support systems will integrate into our daily practice, and command centers will allow clinicians to supervise more and more locations safely in the operating room and the intensive care unit.  The evolution toward artificial intelligence and automation presents an opportunity to augment our ability to deliver care in a more efficient way. The potential benefits of these technologies can be divided into three categories: (1) solutions that automate mundane tasks and relieve clinicians from low-value work, (2) solutions that increase the ability of clinicians to supervise with greater safety efficiency, and (3) solutions that augment clinical and technical skills.

Anesthesiologists spend a considerable amount of time on repetitive, low-value tasks. This has significantly increased with the development of the electronic medical record and has been linked to burnout.  It has also been linked to new risks that may affect patient safety. In the preoperative setting, a significant amount of time is spent reconciling charts and aggregating medical information, work that is often tedious and repetitive. Technology presents a unique opportunity to relieve clinicians from these tasks. Best evidence/practice protocols can be embedded within the electronic medical record and automatically displayed to clinicians, augmenting decisions. Automated alerts have also been used to standardize practice, decrease variability of care, increase adherence to the best evidence, detect unsafe practices, and improve medication safety.

Automation and remote surveillance have probably the most significant potential to affect workforce challenges. The overarching goal is to optimize scheduling to decrease the waste of anesthesia services while at the same time augmenting the ability to cover multiple locations safely and efficiently (“command centers”).  Data collected through the electronic medical record and the anesthesia information management system have already been shown to improve operating room management, billing, and documentation. In parallel, remote surveillance and telemedicine are now allowing the surveillance of multiple locations simultaneously.  This model has proven successful in the intensive care unit. The development of automated/closed-loop systems paired with remote surveillance systems will further enhance our ability to improve access by expanding supervision ratios safely. Command centers for anesthesia have already been developed and tested and may also create an opportunity to monitor patients outside the operating room and at home. Telemedicine solutions, paired with wearable technologies and mobile health solutions, may also allow anesthesiologists to improve the care of surgical patients perioperatively.

Artificial intelligence and closed-loop systems have the potential to augment the care that anesthesiologists provide by enhancing clinical and technical skills.  Numerous studies on artificial intelligence and machine learning have focused on the use of perioperative electronic medical record and anesthesia information management system data that include digital phenotyping of diseases, postoperative outcomes prediction, and forecasting of deterioration, thus directing resources to the highest areas of risk. Numerous articles on fully automated anesthetic delivery have also been published, from automated general anesthesia and automated hemodynamic management to automated sedation for transcatheter aortic valve replacement. These systems should not replace the physician but do have the potential to increase the efficiency and safety of our practice and to augment our ability to extend physician supervision in a safe manner. Some groups have also been working on robotic anesthesia, such as robot-assisted tracheal intubation and robot-assisted ultrasound-guided nerve blocks. 

Although artificial intelligence technologies may allow anesthesiologists to expand their footprint in the perioperative setting, they are not without risks.  If not developed properly, artificial intelligence systems carry a risk of perpetuating inequities. A lack of transparency in the way artificial intelligence solutions are developed can perpetuate distrust among clinicians. Moreover, if not done correctly, these systems could have the exact opposite effect from what they are meant to achieve: increased workload and costs. Finally, we are witnessing the development of unregulated large language models (generative artificial intelligence) that every clinician can use. If done well, this could open the door to even more meaningful applications, such as automating informed consent.

Finances must be part of any discussion of solutions regarding the workforce. We refer the reader to previously published articles on the cost of anesthesia staffing and alternative payment models.  In a highly regulated industry like healthcare, there are a number of government policies, regulations, and other interventions that, although well intentioned, act to distort the market and produce inefficiencies.

There are barriers that impede anesthesiologists working in rural hospitals. The primary reason this imbalance exists is the federal government’s “Rural Pass Through” payment policy.  Insufficient Medicare payments and low patient volume have made it particularly difficult for many rural facilities to attract and retain qualified healthcare clinicians. In response to these challenges, a variety of incentive programs have been enacted to encourage clinicians to practice in rural areas. One such program is the anesthesia rural “pass through” program, which currently only subsidizes nurse anesthetists, thus creating market distortion, rural workforce shortages, and potential adverse healthcare consequences.

The reliance on facility funding to cover staffing costs often can limit staffing coverage and models. Facilities are paid by Center for Medicare and Medicaid Services using Part A funding and have seen cost-of-living adjustments or increases due to inflation. Professional services, including physician services and anesthesia care, are paid using Part B funding. In contrast, the physician fee schedule has not kept up with cost-of-living adjustments and has decreased over the last 20 yr (fig. 3). The American Medical Association and other medical specialties’ associations, including ASA, continue to advocate to the federal government and promote legislation to correct this faulty payment policy. Further, the Center for Medicare and Medicaid Services anesthesia conversion factor is less than 30% of the commercial conversion factor. As the patient population ages with a larger portion of Medicare payers, this low Medicare conversion factor will lead to further financial stress on anesthesiology groups and an increased reliance on facility funding to cover staffing costs.  Finally, staffing models are based on sites and hours that need to be staffed rather than an equation of revenue versus costs. This disconnect results in executives not understanding that more complex anesthesia care is more costly due to lower staffing ratios, specialty-trained anesthesiologists, and lower revenue (billed units per hour of care).

The work of creating and maintaining a high-quality anesthesia/sedation service is not a billable service. Because the director of anesthesia services is responsible for all sedation at a facility, each anesthesiology department should appoint a Medical Director of Procedural Sedation and require the facility to fund this position and commit funds for education and training, quality oversight, administrative staff, and sedation clinician costs.  The lead anesthesiologist should improve operating efficiency by partnering with the nursing staff to improve scheduling, perform evaluations, and assist sedation clinicians before the deterioration of the patient.

Distinguishing between preanesthesia evaluation and a separably billable evaluation and management service can be complicated. After the COVID-19 pandemic, telemedicine has become more accepted, and many patients appreciate this method of communication. These services may now be billable and not have to rely on facility funding. Further, with new technology and algorithms, the preanesthesia clinic can focus on the subset of patients that would benefit from further evaluation.

Finally, creating the right solution is important and cannot be simply about money. The famous saying is “No Money, No Mission,” but the complete saying finishes with “No Mission, No Need for Money.”  We need to ensure that attempts to correct the workforce imbalance improve the quality and care of our patients.

Practice strategies that can be implemented more rapidly need to be considered. Almost all these strategies will rely on the anesthesiologist working in teams with success tied to training, education, consistent implementation, and a stable workforce. Unfortunately, in the current market, the turnover of staff and the reliance on locum staff make it difficult to implement many of the practice solutions that will be discussed. It takes time to develop highly effective and cohesive teams.

One long-term solution to the anesthesia workforce supply–demand imbalance is to increase the number of anesthesiology residency training positions. Growth in residency spots includes both an increase in the number of positions in existing residencies and the establishment of new residency programs. Many of these new programs are being created in nontraditional settings with a collaboration of private-practice anesthesiology groups taking on a new academic mission in nonacademic medical centers.  Although this approach might be appealing in the short run, we should take great care to not diminish our commitment to the other missions of our specialty (e.g., education, research, innovation). We must not compromise the high standards of clinical care as we rigorously train the best and the brightest, and we must ensure that our specialty has a critical mass of highly trained and committed clinical educators, quality and safety scientists, and basic and clinical scientists in our field. Indeed increasing graduate numbers is slow and inefficient due to the lengthy approval and subsequent training periods and thus may not be sufficient to overcome the workforce imbalance in the short run. This approach also holds the inherent risk of creating an oversupply of anesthesiologists over the long term.

In the short term, a practice solution that facility administrators seek is to increase staffing ratios to reduce costs and increase anesthesia coverage. However, executives rarely appreciate the implications of these changes. The staffing costs may not be lower once different hours worked and break staff are included and recent studies suggest that increasing overlapping coverage by anesthesiologists is associated with increased surgical patient morbidity and mortality. Often, the optimal staffing ratio is determined by multiple factors, including the geographic location of sites, the medical comorbidity and age of the patients, and the complexity of the procedures. Increasing staffing ratios also depends on well functioning and stable teams and standardization of care, including preanesthesia evaluation protocols and anesthesia care protocols.  Increasing the ability of anesthesiologists to safely supervise a higher number of sites may be possible with clinical decision support systems to improve the anesthesiologist’s situational awareness and preanesthesia evaluations.  For example, current technology can track the location of patients within the perioperative suite.  Therefore, anesthesiologists receive automatic notification when a patient arrives at the hospital, in holding, and in the operating room. Similarly, automatic alerts from the electronic medical record’s anesthesia record for vital sign changes (e.g., mean arterial pressure of less than 65 mmHg for more than 10 min) or medications (initiation of vasopressor infusions) would improve anesthesiologists’ awareness and subsequent engagement in care. With the advance of artificial intelligence, additional alerts can be created. Further, standardization of preanesthesia assessment and protocols for anesthesia care combined with stable, well functioning teams may also allow for higher staffing ratios.

Another area of work is whether many of our cases in non–operating room anesthetizing sites need an anesthesia team at all. Given the shortage of anesthesia clinicians, moderate sedation provided by well trained sedation teams might suffice. This example of disruptive innovation using nonanesthesia personnel to safely provide some of the rapidly expanding needs for sedation services, must be part of innovative solutions. There are significant challenges to providing quality moderate sedation, including ensuring that (1) sedation is being provided to appropriate patients; (2) sedation teams are properly trained, identify high-risk patients, and know when to call for help; and (3) program oversight is of high quality.

The Center for Medicare and Medicaid Services has recognized the value of anesthesiologists having oversight of sedation services. In the Center for Medicare and Medicaid Services Conditions of Participation for healthcare facilities, the director of anesthesia services is tasked with this oversight.  Abdelmalak et al. have described in detail the oversight and training program utilized at Cleveland Clinic. They note that sedation nurses are only providing moderate sedation (that is, the patient is still responding to verbal stimuli). They describe rigorous education, training, and an oversight and quality program. Since these tasks or responsibilities are not billable services, the work should be considered an added value to the facility and should be supported by hospital/facility funds, which is often the rate-limiting step for a successful program.

Embedded in a moderate sedation program that provides a high level of patient safety is a well-documented process for screening patients for the appropriateness of the service. The anesthesiology department must be involved in developing the screening algorithm. One can envision that the highest quality sedation service would be designed to have the anesthesiologist in the immediate area of the sedation sites, evaluating patients who are screened to be at higher risk, available to assess ongoing sedation, and able to intervene when the sedation level is insufficient.

Like moderate sedation services, a deep sedation service must be created under the oversight of the anesthesiology department. The most common implementation of such a program is in children’s hospitals for noninvasive (e.g., magnetic resonance imaging) or minimally invasive procedures (e.g., intrathecal chemotherapy injections).  The essential elements of a deep sedation service are similar to those of a moderate sedation service. However, the type of clinician that can provide deep sedation is limited to trained physicians not performing the procedure and excludes moderate sedation nurses.

We have deliberately described sedation services before answering the question, “Do the proposed procedures need sedation services or anesthesia care?” In the absence of alternative sedation services, one should not need to spend time addressing the question. If there is a shortage of anesthesia clinicians to cover all anesthetizing sites and an evaluation led by the anesthesiology department determines that sedation services could provide safe patient care, then the anesthesiologists within the facility can work to create a sedation service to meet access needs. In answering the question, one should consider scheduling and geographical variables with an eye toward maximizing available anesthesia personnel to provide services to patients requiring an anesthesia clinician.

Academic anesthesiologists function within a dynamic ecosystem in which patient care, education, research, and social responsibility missions are interconnected and create the future knowledge base of our specialty and future workforce. The ongoing labor shortage has resulted in a prioritization of resources to address the immediate clinical needs in an academic department but has compromised our ability to fulfill our collective missions and create a vibrant future.  Although the prioritization of these missions may vary among academic institutions, they collectively constitute the fundamental objectives of academic medicine. Beyond its immediate adverse effects on patient care, the shortage of anesthesiologists has many significant implications that greatly compromise an academic institution’s ability to fulfill its academic mission.

We utilize systems dynamics, a theory of problem-solving based on feedback control theory, to explore the repercussions of staffing shortages on the educational mission.  Briefly, staffing shortages initiate a series of consequences beyond increased clinical workload, forced overtime, and extended work hours. Staffing shortages create a reinforcing “education gap” feedback loop that affects resident teaching, supervision, and mentorship. As teaching physicians get busier, directly delivering clinical care, their attention to education declines. This education gap translates into poor faculty teaching scores and declining training program evaluations. Measures designed to mitigate the education gap may burden already overextended staff, decrease morale, and increase attrition rates. Education takes focused time and effort, and the current labor shortage has stressed the ability to maintain and protect academic time that is needed for high-quality education.

Some centers may turn to temporary solutions, including per diem and locum tenens staffing. Although this offers immediate relief for staffing shortages, the strategy comes with increased costs and may introduce inconsistency in practice, negatively affecting the learning environment. Financial incentives may also inadvertently steer both current and future anesthesiologists toward prioritizing the clinical mission over the educational mission, resulting in an imbalance in focus. This situation illustrates a classic systems dynamics issue: a reinforcing loop in which initial disruptions exacerbate existing problems.

External factors, including policy changes and economic forces, are introducing new strains on academic centers. Striving to match market salaries for academic faculty demands careful consideration. Most academic departments invest significantly in non–revenue-generating missions, including research, education, and community service, thereby constraining their capacity to compete effectively with the private sector and other academic medical centers that invest little in these areas. Higher salaries in nonacademic settings lure established and aspiring clinician–educators at the very point in their careers when they are best poised to lead our specialty forward with innovative new advances. The everyday reality is that the implementation of financial incentives to help bridge the staffing gap inadvertently incentivizes faculty to forego dedicated academic time in favor of additional clinical shifts at the expense of our academic mission.

Although this discussion focuses primarily on education, its applicability extends to our clinical, research, and social responsibility missions. For similar reasons, the workforce shortage has had a demonstrable impact on other outcomes, including quality and safety, innovation, and health equity. Amid staffing shortages, preserving the academic mission becomes increasingly difficult yet remains pivotal to ensuring the continuous advancements necessary to meet the future needs of our patients.

This article documents the current healthcare crisis in anesthesia due to labor supply–demand imbalance and its implications for access to safe, cost-effective patient care and the future of the specialty. This crisis is also influencing the fiscal health of hospitals due to the disruption of high-revenue services and the costs of labor. The implications transcend a single specialty and compromise the entire healthcare enterprise.

We have built on solutions proposed at the ASA Workforce Summits. Solutions will require both short- and long-term approaches that are multifactorial. Figure 4 illustrates multiple solutions, some of which can be implemented at the local level and some of which are more complex and will require national deliberations that involve many stakeholders. Defining measures and timeframes for success will be an ongoing project.

Proposed solutions can be categorized into several domains (fig. 4).

1. Increase the pipeline and adapt training to emerging healthcare needs. Consideration should be given on a federal level to increasing the number of federally funded graduate medical education slots and to increasing training capacity through academic–community partnerships.
2. Facilitate retention through improvements in the workplace environment. The factors that affect retention include initiatives to address burnout, harassment, incivility, and violence; an inclusive culture; flexible scheduling; and transition to retirement that keep physicians in the workforce.
3. Improve capacity through innovations in practice. These include models for the more efficient delivery of moderate sedation in non–operating room settings and acuity or risk-based models that may allow for greater physician supervision ratios in low-acuity settings.
4. Leverage technology to aid in decision-making and improve the efficiency of care. Technology holds the promise to automate low-value tasks, increase the ability to supervise safely, and augment clinical skills. Consideration should be given to an annual technology summit, which would showcase emergent technologies and identify gaps and opportunities for further development.
5. Address financial constraints including deficiencies in Medicare payment for anesthesiologist services, development of mechanisms of payment for sedation services, and correction of inequities, particularly as related to rural access.

Successfully addressing the workforce imbalance will require a long-term vision, expanding our strategy from quick fixes to sustainable solutions. Closer collaboration between anesthesiologists and hospital administration will focus a critical lens on evaluating service expansions. This ensures thoughtful implementation, carefully balancing demand with long-term sustainability. However, sustainable solutions go beyond resource allocation and should be considered an investment in the future and not a cost. Cultivating flexible work structures and an inclusive workplace culture are essential to maximizing staff retention, which helps preserve expertise and ensure continued excellence. Finally, better coordination between healthcare stakeholders that is grounded in evidence is necessary to best meet the healthcare needs of America.

History has demonstrated that workforce predictions can be unreliable and that some strategies may have unintended consequences. We recommend that the ASA maintain a consistent focus on the workforce and continue to convene an annual stakeholder summit to review trends, monitor progress, and modify strategy with regular reports from the summits to the anesthesiology community, healthcare executives, industry leaders, and policymakers.