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February 2001
Volume 65 |
Number 2
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| Surviving
the Perfect Storm: Challenges Faced by Our Training Programs |
Kevin K. Tremper,
M.D., Ph.D., President Association of Anesthesiology Program
Directors
Simon Gelman, M.D., Ph.D., Immediate Past President Society
of Academic Anesthesiology Chairs
The past decade has seen unprecedented changes in the management
of health care that have placed academic medical centers at significant
financial risk. In the early portion of the decade, managed care
plans grew significantly, reducing fee-for-service income and progressing
toward a capitated environment in some markets. 1
The financial risk was shifting from insurers to the providers.
Hospital patient length of stay was dramatically reduced, resulting
in decreased occupancy and reduced hospitalizations and surgical
procedures along with reimbursement. Health care planners envisioned
a future with primary care gatekeepers who would decrease the need
for specialists.
In 1997, the Health Care Financing Administration (HCFA) capped
the number of residents for graduate medical education reimbursement
and even proposed financial incentives to institutions that would
voluntarily reduce their number of house officers. Academic medical
centers strived to produce a greater number of primary care trainees
to meet the perceived demand for these new gatekeepers of capitated
care. Many academic medical centers expanded their primary care
base by buying practices, thereby ensuring their referrals to
maintain academic and financial viability.
At the height of this push for primary care, the field of anesthesiology
appeared to be targeted as one with an oversupply that would be
especially impacted by decreased surgical procedures resulting
from full capitated care. 2 A shocking
reduction in medical school applicants to anesthesiology programs
occurred in 1995. The graduating CA-3 class in 1994 was 1,843,
while the entering CA-1 class for 1996 was only 745. 3
Although this class was ultimately supplemented to 885, the number
is still approximately 1,000 less than the graduating classes
during the peak years of the early 1990s. 4
Nearly all training programs suffered a substantial drop in their
number of residents, and the field noted a dramatic increase in
the percentage of international medical graduates (IMG) (10 percent
in 1990 to 57 percent in 1999). 3
Managing an academic program while providing the necessary clinical
service was a challenge with the residencies cut in half. This
staffing problem has placed significant stress upon the faculty
of these training programs as well as the financial resources
of the departments and the institutions in which they are inexplicably
bound. To make a difficult financial environment even worse, Congress
passed the Balanced Budget Amendment in 1998 in which HCFA would
progressively reduce graduate medical education (GME) reimbursement
to teaching hospitals. 4, 5
The result has been a progressive decrease in training hospitals’
profitability, where many academic medical centers are either
in the red, some to a dramatic degree, or are predicting progressive
financial difficulties as the Balanced Budget Amendment is implemented.
6 Ironically, this
has occurred during a decade in which the United States’ economy
has been remarkably strong, producing a positive federal budget.
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Table 1:
Current Manpower Needs in Academic Departments
August 2000
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| Response Rate: 66.2% (94/142) |
Yes |
No |
| Additional Faculty Needed? |
91.5% |
8.5% |
| # of Faculty Needed |
326 |
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| Average # Per Department |
3.8 |
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| Additional CRNAs Needed? |
66.5% |
33.5% |
| # of CRNAs Needed |
246 |
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| Average # Per Department |
4.0 |
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Academic departments of anesthesiology enter the new millennium
facing the confluence of three adverse financial pressures: 1)
decreased professional fee reimbursement, 2) working within academic
medical centers that are struggling to remain financially viable
and 3) trying to retain academic faculty in the best job market
for anesthesiologists in 20 years. 7
The reduction in resident class size in the late 1990s has obviously
resulted in the decreased availability of trained anesthesiologists
today. As the overall job market has improved, the academic life
has progressively deteriorated. When the number of residents decrease,
academic faculty are required to spend a greater and greater portion
of their time providing service, thereby limiting time for academic
development. It may be difficult for some faculty to determine
the difference between an academic position and a private position,
other than a lower salary. 8 With
hospitals trying to meet their budgets, there are greater pressures
to shift costs to the academic departments by not providing the
necessary support. The demands for more clinical productivity
with less support have placed academic departments under unprecedented
financial stress. 6
It is the current feeling among anesthesiology training department
chairs that there is a significant shortage of faculty and that
this problem may only become worse over the next three years.
Last August, a survey was sent to all Society of Academic Anesthesiology
Chairs/Association of Anesthesiology Program Directors members
asking them two, two-part questions:
1. Do you currently need additional faculty? If yes, how many
would you like to hire?
2. Do you currently need additional nurse anesthetists? If yes,
how many would you like to hire?
The results are presented in Table 1. There
are 326 open faculty positions in the 66 percent of departments
that responded to the survey (3.8 per department). If the rate
of open faculty positions is applied to all residency programs,
there would be 490 openings in our academic departments as of
August 2000 and nearly 370 positions for nurse anesthetists in
those departments. This is very disconcerting since most academic
departments recruit their new faculty during the summer, are therefore
usually staffed at the highest levels by the end of August and
lose faculty to community practices and attrition throughout the
academic year.
How much and how quickly those situations will improve is unclear.
The size of entering resident classes over the past few years
has progressively increased 9,10
[Table 2]. Unfortunately, since a large
percentage of those residents are IMGs, it is unknown how many
of those trainees will be able to enter the U.S. market due to
issues relating to their visa status. Residents who have J-1 training
visas must return to their home country after the completion of
their training for a minimum of two years before applying for
an immigration visa. The graduating classes of 2001, 2002 and
2003 should increase in size, but the number of American medical
graduates (AMGs) is only 471, 632 and 811, respectively. This
is well below the AMG graduates of the mid-1990s, which ranged
from 1,358 to 1,547 [Table 2]. For a more
complete description of the residency composition and numbers,
see the article
by Alan W. Grogono, M.D., in the November 2000 NEWSLETTER.
10
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Table 2: AMG
and IMG Resident Graduates
1993 through 2003
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Clearly, if we are to maintain our residency programs, we require
faculty to provide the clinical training as well as to continue
to invest in the academic base of our specialty. Without that
academic investment to develop new knowledge in the field of anesthesiology,
the future of our medical specialty is at risk. This current problem
should be a wake-up call to those in our specialty who felt that
the work force was glutted with too many practitioners and hoped
for a reduction in the number of residents. The shortage of trained
anesthesiologists that we see today may improve the job market
for anesthesiologists in the short run but may be a threat to
the future of our specialty in the long run.
We need to make hospital deans and executives aware of the dwindling
physician resources within our specialty. We need to inform medical
students of the opportunities in our specialty from a clinical
and academic perspective. As a specialty, we are obligated to
provide the medical care needed by our patients and to develop
new knowledge to meet the needs of future generations.
References:
1. Rogers MC, Snyderman R, Rogers EZ. Cultural
and organizational implications at academic managed-care networks.
N Engl J Med. 1994; 331:1374-1377.
2. Anders G. Once a hot specialty, anesthesiology
cools as insurers scale back. Wall Street Journal. March 17, 1995.
3. Grogono AW: Update on Residency Composition
1960-1999. ASA Newsl. 1999; 63(11):17-19.
4. Implementing BBA Provision. Federal Register
412.105. Direct Graduate Medical Education 413.86. May 12, 1998.
5. Association of American Medical Colleges Fact
Sheet. Association of American Medical Colleges. Washington, DC:
1999; 3(5).
6. Reves JG, Greene NM. Anesthesiology and the
academic medical center: Place and promise at the start of the
new millennium. Chapter 3: The present (1990-2000). Int Anesthesiol
Clin. 2000; 38(2):45-96.
7. Johnstone RE, Hosaflook C. Financial impact
if payers use Medicare rates. Anesthesiology. 2000; 93:852-857.
8. Academic Practice Faculty Compensation and
Production Survey. Medical Group Management Association. Englewood,
CO; 2000:14.
9. Personal communication. Frank Hughes, Ph.D.,
American Board of Anesthesiology; September 2000.
10. Grogono AW. Residency composition and numbers
graduating. ASA Newsl. 2000; 64(11):16-19.
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Kevin
K. Tremper, M.D., Ph.D., is Professor and Chair, Department
of Anesthesiology, University of Michigan, Ann Arbor, Michigan. |
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Simon
Gelman, M.D., Ph.D., is Chair, Department of Anesthesiology,
Perioperative and Pain Medicine, Brigham and Women's Hospital,
Boston, Massachusetts |
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