WHO WILL BE PROVIDING ANESTHESIA CARE 10 YEARS FROM NOW?

Imagine this: It’s the year 2034. You’re diagnosed with gallstones and you need to have your gallbladder removed. This will require an operating room staffed with a surgeon, a nurse, a scrub technician, and an anesthesia professional. If the current trend of inadequate numbers of anesthesia clinicians in the United States is not reversed, this insufficient supply will be a major problem. Non-emergency surgery may be delayed for days, weeks, or longer.

The August 2024 issue of our specialty’s primary journal, Anesthesiology, included the landmark paper Closing the chasm: Understanding and addressing the anesthesia workforce supply and demand imbalance. This publication described the imbalance in the supply and demand of the anesthesia workforce since the COVID pandemic. Post-COVID we’ve seen a marked rise in the demand for anesthesia care, which has outstripped the supply of anesthesia clinicians. This shortage has hampered the ability of healthcare systems to provide surgical services. Before COVID, 35% of facilities reported an anesthesia staffing shortage. Two years after the pandemic, 78% of facilities reported an anesthesia staffing shortage.

In a professional labor market such as anesthesia providers, the supply of qualified clinicians cannot increase fast enough to ease the pressures resulting from a markedly increasing demand. The regulation of the number of MD residency and CRNA training positions, and the duration of time required to train new professionals, impede the ability to rapidly increase the supply of clinicians entering the workforce.

Specific trends have led to the anesthesia workforce supply–demand relationship. Per the Anesthesiology article, these trends include a) an aging patient population, b) an evolution of surgical procedures and procedural areas, c) the number of anesthesia providers entering the workforce, and d) the changing generational preferences and attitudes of these providers.

Let’s examine how the Anesthesiology article described each of these trends:

An Aging Population

In 2023, more than 58 million Americans were 65 years of age or older (17.3% of the population). In 2050, there will be 90 million Americans 65 years of age or older.  Older patients have more medical problems, require a disproportionately increased number of surgeries, and are more susceptible to medical complications.

Evolution of Procedures and Procedural Areas

Procedures that used to be hospital-based have increasingly moved into outpatient settings and physician’s offices. This trend toward minimally invasive surgery has led to older and sicker patients who were at too high a risk for open procedures, to now be eligible for new noninvasive procedures. Noninvasive surgical procedures in hospitals, such as trans catheterization heart valve replacements, are often done outside a traditional operating room, which spreads out the anesthesia workforce and leads to an increased demand in remote non–operating room settings. This leads to lateral spread of anesthesia providers and scheduling challenges.

The Current Anesthesia Workforce in the United States

The Center for Medicare and Medicaid Services lists 97,000 anesthesia professionals in the United States who have billed Medicare in the last 6 to 12 months. The Center for Anesthesia Workforce Studies estimates that current clinically active anesthesia professionals are made up of 43,500 anesthesiologists, 50,000 nurse anesthetists, and 3,200 anesthesiologist assistants. They also estimate 5,200 anesthesia professionals entered the workforce from training programs in 2023: 1,900 anesthesiologists, 3,000 nurse anesthetists, and 300 anesthesiologist assistants. They estimate 4,800 anesthesia professionals left the workforce in 2022, including 2,500 anesthesiologists, 2,200 nurse anesthetists, and 65 anesthesiologist assistants. This represents a small net increase (400 professionals) in workforce supply, but this quantity is insufficient to keep up with the increase in demand. The net decrease in MD anesthesiologists was 2500 – 1900 = 600.

The Automation of Low-value Tasks

In the future, the delivery of anesthesia is expected to become more automated.  Command centers will likely allow professionals to supervise an increased number of locations safely in the operating room. Anesthesiologists currently spend a significant amount of time working with electronic medical record (EMR) entries, and the advent of the EMR has been linked to burnout. Artificial intelligence technology and automation of the EMR present potential opportunities to relieve clinicians from repetitive tasks.

Augmenting Anesthesia Clinical and Technical Skills

Published data shows artificial intelligence and closed-loop systems have the potential to simplify aspects of maintenance anesthesia care. Robotic models exist for fully automated anesthetic delivery, computer-controlled general anesthesia level, computer-controlled hemodynamic management, and computer-controlled sedation. These robotic systems are not likely to replace anesthesia professionals, but may increase the efficiency and safety of our practice and increase the ability to simultaneously supervise multiple anesthetizing locations in a safe manner. It’s speculated that mechanical robotic anesthesia advances, such as robot-assisted tracheal intubation and robot-assisted ultrasound-guided nerve blocks, may someday decrease anesthesia manpower needs.

The Invisible Hand of Economics: How Financial Reimbursement Affects Anesthesia Staffing

Abysmally low Medicare payments for anesthesia professionals affect the marketplace. The Medicare anesthesia physician fee schedule has not kept up with cost-of-living adjustments over the last twenty years. The current Medicare anesthesia conversion factor is less than 30% of the commercial conversion factor. Imagine this occurred in your workplace: that on some days you worked for the government, and you were paid only 30 percent of your usual income for your effort. What effect would this have? More likely than not you would seek an alternative career.

Potential Solutions:

The Anesthesiology article proposes the following solutions to the anesthesia labor supply–demand imbalance:

1. Increase the pipeline. “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.” Strategies include increasing the number of positions in existing residencies, establishing new residency programs, shortening the duration of anesthesia training, and recruiting anesthesiologists from other countries. Increasing the number of anesthesiology professionals will be a slow process, due to the time required to train them, and will not quickly overcome the workforce imbalance. This approach also presents the risk of creating an oversupply of anesthesiology clinicians over the long term.

2. Facilitate retention of anesthesia professionals. “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. “Technology holds the promise to automate low-value tasks, increase the ability to supervise safely, and augment clinical skills.”

5. Address financial constraints“. . . including deficiencies in Medicare payment for anesthesiologist services.”

My comments:

As a hybrid private-practice/academic clinician who has practiced anesthesiology since the 1980s, I’d make the following observations on the current supply-demand imbalance in my field and the worries about the future:

1. Anesthesiology continues to be a popular residency choice among medical students, and was the 7^th highest specialty in number of applicants in 2019. Because of the low supply of anesthesiologists, an abundance of job opportunities awaits graduates of anesthesia residencies.
2. It’s a fact that there will be an inadequate number of anesthesia professionals (MDs, CRNAs, and AAs) in the foreseeable future. While we wait for an eventual increased output from training programs, some facilities will indeed be understaffed, particularly facilities which offer low reimbursement. There will be delays and some rationing of surgical procedures. Consolidation of surgery locations from understaffed rural facilities to urban/suburban hospitals and surgery centers is likely.
3. Enticing anesthesia professionals to prolong their careers, i.e. not retire early, will require anti-burnout measures at the workplace.
4. Enticing anesthesia professionals to prolong their careers, i.e. not retire early, will require Medicare to increase reimbursement from the current 30 cents on the dollar compared to the commercial rates. Aging anesthesiologists will prefer to go fishing than do difficult geriatric anesthetics for discount wages.
5. Artificial intelligence and robotics will reduce the number of anesthesiologists required to manage a suite of operating rooms. Look forward to a time when AI modules provide routine medical care while fewer physicians oversee the process. (see my novel Doctor Vita for a vision of this future.)
6. It’s unlikely that robots will replace the manual skills of anesthesia professionals (e.g. managing airways, placing breathing tubes, intravascular catheters, and pain blocks). The hands of an anesthesiologist cannot be replaced by machinery.
7. There will be a market for quality medical care. Just as some wealthy individuals currently purchase the services of a concierge internist, wealthy patients will likely spend money to purchase access to better surgical care.
8. Could Medicare for all, or universal healthcare, resolve the injustice of inadequate health care access? If there are an inadequate number of medical professionals, the vision of universal access to medical care for all will not become reality.
9. Increasing the number of anesthesiologists, CRNAs, and anesthesiologist assistants is the obvious key to the supply-demand imbalance. I believe medical leadership will focus on this solution, but as described above, this solution will take years to change the marketplace.