Anesthesiologist shortages contribute care delivery challenges in the United States (Anesth Analg 2019;129:294-300). Addressing the crisis of access to anesthetic care in our underserved populations requires the incorporation of specific education and training enhancements within our current residency programs about the lifestyle and career opportunities often present in rural settings. Developing stand-alone rural programs, tracks, and other innovative solutions to ensure that anesthesia and perioperative care are available to every patient, regardless of the community or facility, is important to the Accreditation Council for Graduate Medical Education (ACGME). In rural, underserved areas, Indigenous peoples and migrant workers may face difficulties accessing health care due to cultural and language barriers, work-related mobility, and documentation status related to fear of openly accessing care. These patients warrant special considerations for perioperative risk stratification, optimizing outcomes toward health equity. Indeed, global health equity (GHE) education is relevant for all practice settings, as described by Wollner et al. in “Why every anesthesia trainee should receive global health equity education” (Can J Anaesth 2020;67:924-35). Learning experiences in underserved locations play a crucial role in fostering trainees’ comprehensive understanding of the interconnection between access to care and the training necessary to provide quality health care.
“In response to current physician shortages, additional residency positions have been made available through the Consolidated Appropriations Act (CAA), 2021. Specifically, section 126 calls for increases in residency training positions by 200 each fiscal year, starting in 2023, for up to a total of 1,000 new Medicare-funded GME positions.”
Achieving the goals of access and equity
So, what is the good news for actually achieving these goals of increased access and equity? In response to current physician shortages, additional residency positions have been made available through the Consolidated Appropriations Act (CAA), 2021. Specifically, section 126 calls for increases in residency training positions by 200 each fiscal year, starting in 2023, for up to a total of 1,000 new Medicare-funded GME positions. Section 127, Promoting Rural Hospital GME Funding Opportunity, allows rural teaching hospitals participating in an accredited rural track program (RTP) to receive increases to their full-time equivalent caps (asamonitor.pub/3JS4tBD). These changes create an atmosphere of opportunity for training anesthesiology residents to practice in these settings, which is the first step to redistribution of care resources. To this end, the ACGME has established a framework and processes to promote the development of RTPs in GME. To date, there are no anesthesiology programs that have established or applied for ACGME-designated RTPs. The ACGME RTP designation is independent of any rural track designation by the Centers for Medicare & Medicaid Services (CMS) and therefore is important to consider as it does not guarantee that a program will meet CMS eligibility requirements for GME or other financial support. Whether to start a new training program, build on an existing program, or become ACGME-designated and/or eligible for CMS funding requires an understanding of the costs and benefits of establishing rural training for your residents.
In our own program, the cost of sending residents to our rural locations (two residents supervised by one faculty member) is offset by two factors: 1) Revenue generated by keeping ORs open in those facilities (which often lack resources to meet peak demand) and 2) Reduction in the number of CRNAs that need to be scheduled at those facilities on that particular day. In this context, the cost savings of salary/benefits of utilizing two residents and their attending (versus two CRNAs) combined with anesthetics billed creates a more positive fiduciary outcome for the rural location when it is possible to use the CRNAs elsewhere or arrange for them to be on vacation. This should not be interpreted as a displacement of the CRNAs from employment. It simply creates the opportunity for rural hospitals to share full-time staff equivalents between facilities and allows vacations and CME to be scheduled without locum coverage.
The dearth of core faculty educators with expertise in rural anesthesia inhibits our readiness to apply as an ACGME-designated RTP to a greater degree than the financial considerations. We anticipate that as our program grows, we will be creating our own crop of qualified rural-educator anesthesiologists, and this issue will resolve itself. We envision a time when the excess of qualified instructors in the rural affiliates will help periodically reduce unmet demands in our urban facilities. We are building a group of faculty not tied to a single hospital, but rather with the flexibility to provide care where needed and to educate our residents in appropriate rural learning environments.
Regarding residency training, our current rural locations would not be able to support the requirement to have 50% of training occur only in those areas, as the total combined number of ORs and procedures performed in those facilities is dictated by the needs of the populations served, and the current referral patterns often result in patients being seen and scheduled in urban facilities of our health system. We are very aware that many procedures at our urban facilities could just as easily and more conveniently be done in the rural affiliates. It is the intent to realign this pattern to the available ORs, enhancing both the patient experience (by reducing travel) and financial positions of the affiliate facilities. The referral patterns and locations of the practices of the surgeons providing the care are more relevant to the mis-location of services than the OR volume capacity of the affiliates, which have abundant unused OR time.
Generating enthusiasm for practicing in underserved settings
Training in underserved settings in international locations is traditionally a desirable elective for residents. We have had faculty travel for medical missions to underserved countries. They can take residents along, but the eagerness of doing such a rotation during recruitment season sometimes abates during residency. The U.S. Department of State occasionally issues travel warnings, and sometimes we find ourselves in a pandemic. Realistically, how much of an impact will a few weeks in an underserved country or region make on the resident’s overall education anyway? What’s driving this desire to travel the world? “I want to provide anesthesia without the same resources we have here” and “I’d like to help care for an underserved population” are two common sentiments expressed. We believe that for many, the opportunity to have those same experiences in rural U.S. settings may be of an equivalent educational value. Retaining our trainees to practice in these rural settings is the challenge; but the potential payoff of being able to make and sustain improvements in our national population health is likely more tangible.
ACGME and RTP designation
Laney McDougal is the Director of the Medically Underserved Areas/Populations and Graduate Medical Education for the ACGME. In reviewing the online ACGME guidelines, and via electronic communications, the following questions and answers were collected, with the interested reader encouraged to follow up with resources cited below:
How much time do trainees need to spend in the rural locations for the program to qualify as an RTP?
Criteria for RTP designation includes sending the rural track residents/fellows to new rural PPS or nonprovider site(s) for more than 50% of the program duration.
Which ACGME RTP designation process should a program choose?
If you already have an ACGME-accredited program within your sponsoring institution and want to create an RTP within that same specialty, you can either pursue designation as a rural track within the existing program or as a new program at application. Programs must be in Continued Accreditation status to pursue a designation within an existing ACGME-accredited program. If you do not yet have an ACGME-accredited program within your sponsoring institution, you can request RTP designation at application for program accreditation.
We don’t qualify as a program or track, but send residents to rural locations. Can we just call this a “rural pathway”?
The ACGME RTP designation is independent of any rural track designation by CMS and does not guarantee that a program will meet CMS eligibility requirements for GME or other financial support. What a program calls themselves is their decision, and they can use whatever term they would like for recruitment purposes.
Why do we need 50% training at rural sites? That’s a challenge for procedural specialties.
The ACGME RTP designation was built to align with CMS “rural track program” policy and therefore has a criterion of more than 50% of the program duration in a rural area. Programs in any specialty seeking this designation must still meet the accreditation requirements in their respective specialty, including the minimum procedure volume requirements. The percentage of time in a rural area is not required for general ACGME accreditation purposes, and designation is considered separately and independent of accreditation and funding.
How are the programs evaluated for compliance?
The duration threshold in the rural site(s) is evaluated by the ACGME using the RTP Rotation Information Form, which is available on the RTP Designation webpage (asamonitor.pub/46G2Fp6).
What is the best step forward if a residency wants to apply for an RTP designation?
Programs are encouraged to contact the executive director of the relevant review committee early in the process of developing RTPs (regardless of the RTP process pursued) to discuss their plans and the review committee expectations for demonstrating substantial compliance with the program requirements. Programs are also encouraged to review the ACGME RTP Designation webpage for FAQs, instructions, and additional information, and to contact Laney McDougal at email@example.com with questions about the designation process (asamonitor.pub/46G2Fp6).