- Expand the size of existing residencies
- Start new residencies
- Shorten the duration of residency
- Recruit more anesthesiologists from other countries.
This article will review the possibilities.
Expanding existing residencies
This straightforward approach is already happening across the country. Current residencies vary in size from three to about 40 per year, so it’s possible for many residencies to get bigger within the constraint of available teaching cases. However, there has been no increase in federally funded residency positions since 1996, with the exception of a small recent program tied to underserved geographies. Thus, institutions must justify – and pay for – new positions based on internal economics of care delivery. Because anesthesiology residents contribute to the daily workforce, and because the hospital has a need to get procedures covered, there is likely more benefit than cost in expansion. Academically, the ideal size for an anesthesiology residency is undetermined. One would want the optimum class size for didactic learning, critical mass for networking and culture, sufficiently complex cases, and the logistic sweet spot for an efficient support structure.
Starting new residencies
An exciting and constructive occurrence in recent years has been the creation of new anesthesiology residencies in large community hospitals. In some cases, e.g., the Sunrise Health Graduate Medical Education Consortium Anesthesiology Residency in Las Vegas, the program has no connection with a medical school or a traditional university hospital. The CME sponsor of this residency is the Hospital Corporation of America, and the program graduated its first class of six in 2021. The majority of graduates in the first two classes have joined local groups in the Las Vegas area.
Case type and volume are not typically barriers to anesthesia residencies in the U.S.; there are many large, non-university hospitals in the U.S. now providing a full range of cardiac, transplant, pediatric, and high-risk cases. Nor is faculty engagement likely to be an issue, as most anesthesiologists already do some teaching of SRNAs, CAAs, oral surgeons, medical students, nursing students, or EMTs and are usually happy to work in 1:1 or 1:2 ratios with residents. Didactic teaching is becoming simpler as well with the emergence of distance learning options such as ASA’s Anesthesia Toolbox. National-level resources like these can be used to fill in for gaps in local expertise. As an illustration of the ability to offer basic didactics remotely, many of the largest CAA and CRNA training programs now offer most of their classroom work this way.
The most common challenges to initial and continuing accreditation of community-based anesthesiology residencies are likely to be funding and “scholarly activity.” Some hospital systems have chosen to fund residencies internally. As noted above, these investments likely offer favorable economic returns over time. Even so, a reasonable target for ASA advocacy might be expanded funding from the Centers for Medicare & Medicaid Services to increase hospital caps. The question will be how many positions to ask for and when to stop expanding. While more graduates are needed today, new or expanded residencies will not increase the workforce for at least five years, at which time the demand might be markedly different. Among the many factors that could affect future demand are the potential for new technology and new models of care to reduce the need for anesthesiologists at the bedside of patients having low-risk sedation, as for cataracts or screening colonoscopy. Other articles in this Monitor issue will explore these topics.
The requirement for programs to demonstrate ongoing research and publication may prove difficult for community-based residencies, especially as they come up for recertification. Active engagement of the residents in performance improvement and health services research projects can provide some substrate for scholarly activity, as can promotion of participation in ASA and state society meetings or collaboration with academic neighbors. ASA engagement with the ACGME Review Committee for Anesthesiology might lead to evolution in standards for training – e.g., a broader view of what constitutes scholarly activity – that will benefit both workforce expansion and the reputation of our profession in the long term.
There has been considerable discussion about the evolution of anesthesiology training to a competency-based rather than time-based model. One potential advantage of this would be shortening the length of training for motivated and capable physicians, providing earlier entry of qualified residents into the practicing workforce. While it makes intuitive sense that time per se does not equate to desired learning, transition of a 100-year-old training model will be a challenge. A competency-based model will require granular definition of what exactly we want residents to learn. This is something that might prove difficult to articulate, although the ACGME Anesthesiology Milestones are an important step in the right direction. To the extent that assessment for competency will require human opinions, there is potential for both conscious and unconscious bias. Creating a system acceptable to all may prove challenging.
New rules will inevitably inspire gamesmanship and unintended consequences. Consider the target population: anesthesiology residents today are highly selective and highly competitive individuals who will gravitate toward expedited standards for graduation like moths to a flame. Having 90% of residents graduate early might be good for short-term workforce needs but bad in other ways; for instance, internal competition for cases critical to graduation (e.g., cardiac cases, craniotomies). There are also logistical issues that must be resolved in harmonizing competency-based training with a time-based world. These include planning for available workforce in the short term and understanding how many residency positions to match each year.
Compared to practice in some other countries, anesthesiology in the U.S. is both cutting edge and well-compensated, and thus highly attractive. At present, however, the number of anesthesiologists coming from other countries is limited by regulatory barriers. In order to practice in the U.S., an international anesthesiologist must pass the USMLE exam, including proficiency in English, and must complete an anesthesia residency in the U.S., complete ABA certification through the Alternate Entry Path (AEP) or practice in a medically underserved area under a Faculty Temporary License (FTL). The AEP program allows selected international faculty to qualify for ABA certification after four years; sites are currently limited to four AEP faculty at a time.
Requirements for FTLs vary from state to state, as does the amount of time the anesthesiologist must practice at the sponsoring institution before leaving. Subsequent opportunities to practice may be limited by the lack of ABA certification. International anesthesiologists seeking to practice in the U.S. must also meet visa or green card requirements for full-time work and must qualify for a state medical license. As an example, the Texas Medical Board will issue an FTL for international physicians who have done at least two years of postgraduate training (not limited to the U.S.) within a training institution that becomes the sponsor. This is a renewable yearly permit. Each year under this permit counts as postgraduate education in the U.S., which can then be used to obtain a full license. The Federation of State Medical Boards offers an initial medical licensure summary by state that includes international medical graduate requirements (asamonitor.pub/3xA1nMi).
Expanding the AEP or FTL programs to a broader swath of hospitals might help alleviate workforce issues. In the extreme, allowing reciprocity of certification with other boards (e.g., Great Britain, Australia, Germany) could enable rapid expansion of the U.S. anesthesia workforce. As with expansion of residencies, however, this approach might be difficult to revoke if and when the workforce crisis passes.
There are a number of approaches available to increase the supply of anesthesiologists, although most will take years to have a noticeable impact. Among the barriers to rapid expansion are limited federal funding for new residency places, regulatory barriers to licensing anesthesiologists from abroad, and uncertainty regarding the desirable long-term size of the anesthesiologist workforce.