Authors: Jonathan D. Katz, M.D.; Amanda Burden, M.D.
ASA Monitor 01 2018, Vol.82, 26-28.
The United States is facing a projected physician shortage. According to a report released by the Association of American Medical Colleges (AAMC), there could be a shortfall of between 40,800 and 104,900 physicians by the year 2030.1 A recent analysis projects a shortage of more than 4,400 anesthesiologists by the year 2020.2
One significant component of this projected shortfall is the population of clinicians who take a temporary leave of absence from practice. It is estimated that as many as 11 percent of pediatricians take a leave from practice for six months or greater at some point during their careers.3 And the American Congress of Obstetricians and Gynecologists considers it a sufficiently frequent event that they declared re-entry as the “issue of the year” in 2012.4 Data are not available to estimate how many anesthesiologists fit into this category. All totaled, as many as 10,000 physicians per year who have taken temporary leave are potential candidates to re-enter medical practice and contribute in efforts to address shortages.5
“Re-entry” in this context is defined as a return to clinical practice in the discipline in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment.6 The term describes physicians who were previously in good standing and voluntarily chose to take a leave of absence. It is distinct from “remediation,” in which a physician has been disciplined or suspended and is required to undergo mandated assessment and clinical supervision, or “retraining,” in which a physician plans to enter a new clinical area or learn a new procedure.
Re-entry into anesthetic practice is challenging. The successful candidate must meet state licensing regulations and credentialing policies of health care institutions and professional liability carriers.7 More important, he/she must demonstrate continued mastery of the core competencies required of an attending anesthesiologist.6,8
“By employing rigorous re-training techniques, along with a structured re-entry strategy, many of these physicians can successfully resume their careers. Organized medicine can play a pivotal role by establishing nationally recognized standards for re-entry programs and a centralized database of programs that meet these standards.”
Two factors play major roles in the course and ultimate success of the re-entry process. The first is the duration of the absence. If the clinical hiatus is brief, a short period of re-acclimatization may be all that is necessary during re-entry. If the absence from clinical practice is more extended, a formal re-entry process may be required. Unfortunately, there is little agreement as to what time interval constitutes a “prolonged absence” that warrants a structured re-entry process. Of the state medical boards that require completion of a re-entry program after a prolonged absence, the time period that triggers this requirement varies from one to five years.9 The Australian and New Zealand College of Anaesthetists (ANZCA) recommends that anesthetists complete a refresher program after an absence of greater than one year.10 The American Medical Association (AMA) recommends participation in a formal re-entry program for those physicians who have been absent from practice for two or more years.11 ASA has not yet established an official guidance on this topic.
The second important factor impacting re-entry is the circumstance under which the absence was initiated. In many cases, an anesthesiologist will voluntarily choose to suspend his/her practice to devote time to a variety of non-clinical activities, including family responsibilities, or to pursue an alternative career.12 A second scenario involves involuntary absence, as occurs with personal illness, impairment or disciplinary action. As indicated in the AMA definition (above), return to practice after impairment, suspension or disciplinary action requires special consideration and falls outside of this discussion. The advisability of re-entry for an anesthesiologist after suspension for substance use disorder is particularly controversial and has evoked vigorous debate.13
Regardless of the reason that a physician has been away from clinical practice, there are advantages to enrolling in a formal program when considering re-entry. A qualified program will optimally provide the following services: 1) an objective assessment of the current clinical competence of the re-entry candidate focused upon an analysis of his/her medical knowledge and clinical skills (he/she knows what to do and knows how to do it); 2) a customized refresher program designed to provide individual education geared toward the candidate’s specific needs; 3) a clinical pre-ceptorship to allow the physician to resume practice of the skills and procedures specific to his/her practice in a supervised and protected environment; 4) a comprehensive evaluation at the end of the program to ensure the candidate is thoroughly competent to return to clinical practice (he/she does what he/she knows how to do).7,14
One of the larger challenges to the returning physician is finding an appropriate educational program and meeting the considerable personal costs. Additional difficulties include navigating through the professional liability obstacles to create an appropriate clinical preceptorship. Some programs have added simulation education to provide a customized individual education program that will permit the candidate to refresh and practice skills in a protected environment. Simulation has proven to be particularly useful as a training tool for candidates in their efforts to become re-acclimated to the complex dynamic environment of the O.R., where prioritization of decisions and tasks in a continually evolving environment is essential.14 –16 Simulation is also showing promise as an aide in the overall evaluation of competence among anesthesiologists preparing to return to practice.17
There are a limited number of re-entry programs currently available in the U.S., and no central accreditation agency to ensure quality in any individual program. Some of the programs that were developed specifically for anesthesiologists no longer exist and others remain active on a limited basis or restrict their enrollees to those who are alumni of their own residency program. Although it is not specific to the unique demands of the specialty of anesthesiology, the Physician Reentry into the Workforce Project is a helpful resource for information regarding existing programs for the medical community at large.18 Additional details with links to resources for anesthesiologists interested in re-entry programs can be found along with other Quality and Regulatory Affairs content on the ASA website.19 It is encouraging to note that those successful candidates who do enlist in and complete a rigorous and well-structured program can often resume the safe practice of anesthesiology.15,20
Anesthesiologists who voluntarily take a temporary leave of absence from practice and subsequently choose to return to clinical activities represent an important public health resource. Significant questions remain about the best approach to assist returning physician in this process. By employing rigorous re-training techniques, along with a structured re-entry strategy, many of these physicians can successfully resume their careers. Organized medicine can play a pivotal role by establishing nationally recognized standards for re-entry programs and a centralized database of programs that meet these standards.
Markit, IHS, for Association of American Medical Colleges. The complexities of physician supply and demand: projections from 2015 to 2030. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/c9/db/c9dbe9de-aabf-457f-aee7-1d3d554ff281/aamc_projections_update_2017_final_-_june_12.pdf. Published February 28, 2017. Last accessed October 5, 2017.
Daugherty L, Benito RF, Kumar KB, Michaud PC. An analysis of the labor markets for anesthesiology. http://www.rand.org/pubs/technical_reports/TR688.html. Published 2010. Last accessed October 5, 2017.
Jewett EA, Brotherton SE, Ruch-Ross H . A national survey of ‘inactive’ physicians in the United States of America: enticements to reentry. Hum Resour Health. 2011;9:7.
American College of Obstetricians and Gynecologists Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 523: re-entering the practice of obstetrics and gynecology. Obstet Gynecol. 2012;119(5):1066–1069.
Grace ES, Korinek EJ, Weitzel LB, Wentz DK . Physicians reentering clinical practice: characteristics and clinical abilities. J Contin Educ Health Prof. 2011;31(1):49–55.
American Medical Association. Bibliography on physician reentry and reentry-related resources. http://www.ama-assn.org/ama1/pub/upload/mm/377/cmerpt_6a-08.pdf. Last accessed October 5, 2017.
Kenagy GP, Schneidman BS, Barzansky B, Dalton C, Sirio CA, Skochelak SE . Guiding principles for physician reentry programs. J Contin Educ Health Prof. 2011;31(2):117–121.
Tetzlaff JE . Assessment of competency in anesthesiology. Anesthesiology. 2007;106(4):812–825.
Physician Re-entry. In: State Medical Licensure Requirements and Statistics, 2013. Chicago, IL: American Medical Association; 2013. https://www.ama-assn.org/sites/default/files/media-browser/public/med-ed-products/physician-reentry-bibliography_0.pdf; Last accessed October 5, 2017.
Australian and New Zealand College of Anaesthetists (ANZCA). Recommendations on practice reentry for a specialist anaes-thetist (PS50). http://www.anzca.edu.au/documents/ps50-2013-recommendations-on-practice-re-entry-for.pdf. Published February 2004. Last updated 2013. Last accessed October 5, 2017.
American Medical Association Council on Medical Education. Report 6 of the Council on Medical Education (A-08): Physician reentry. http://www.amaassn.org/ama1/pub/upload/mm/377/cmerpt_6a-08.pdf. Last accessed October 5, 2017.
Mark S, Gupta J . Reentry into clinical practice: challenges and strategies. JAMA. 2002;288(9):1091–1096.
Oreskovich MR, Caldeiro RM . Anesthesiologists recovering from chemical dependency: can they safely return to the operating room? Mayo Clin Proc.2009;84(7):576–580.
Steadman RH, Cole DJ . Assessing competence for reentry: what matters most? Anesthesiology. 2013;119(1):16–18.
DeMaria SJr, Samuelson ST, Schwartz AD, Sim AJ, Levine AI . Simulation-based assessment and retraining for the anesthesiologist seeking reentry to clinical practice: a case series. Anesthesiology. 2013;119(1):206–217.
Goldberg A, Samuelson S, Levine A, DeMaria S . High-stakes simulation-based assessment for retraining and returning physicians to practice. International anesthesiology clinics. 2015 Oct 1;53(4):70–80.
Chin M, Lagasse RS . Assessment of competence: developing trends and ethical considerations. Current Opinion in Anesthesiology. 2017 Apr 1;30(2):236–41.
Physician Reentry website. http://www.physicianreentry.org. Last accessed October 5, 2017.
Quality and Regulatory Affairs Common Questions. American Society of Anesthesiologists website. http://www.asahq.org/quality-and-practice-management/quality-and-regulatory-affairs/qra-member-resources/qra-common-questions. Last accessed October 5, 2017.
Larson CPJr, Steadman RH . An advanced specialty training program in anesthesiology: a special educational fellowship designed to return community anesthesiologists to clinical practice. Anesth Analg. 2006;103(1):126–130.
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