April 2001
Volume 65 |
Number 4
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| Where
Have All the Anesthesiologists Gone? Analysis of the National
Anesthesia Worker Shortage |
Gifford Eckhout, M.D.
Armin Schubert, M.D.
Anyone who has tried to recruit a new anesthesiologist lately
has experienced part of a nationwide phenomenon: Both physician
and nonphysician anesthesia personnel are in short supply. As
a result, starting salaries are on the increase, recruiting specialists
are working overtime, and department chairs are struggling with
recruitment and retention of anesthesia personnel.
How did we get here?
In 1994, ASA commissioned a report by Abt Associates on future
employment needs in anesthesiology. The report made several assumptions,
which in hindsight were not accurate. This included operating
room utilization of 90 percent, no growth in surgical procedures
(despite an aging population and surgical advances) and unabated
use of physician extenders. Based on different scenarios of physician
intensity, Abt predicted an oversupply of anesthesiologists for
the foreseeable future. At the same time, the Clinton Administration
started discussions of large-scale health reform and the Accreditation
Council for Graduate Medical Education in 1994 recommended limiting
the total number of residents to 110 percent of the previous year's
U.S. medical graduates and limiting specialist training to 50
percent of all positions. Medical school deans, seeing the writing
on the wall, discouraged graduating students from pursuing specialties
such as anesthesiology.
As a result, CA-1 positions decreased dramatically from 1,873
in 1994 to 745 in 1996. Moreover, the number of American medical
graduates (AMGs) entering anesthesiology began a precipitous decline.
The percentage of graduating anesthesiology residents from U.S.
medical schools dropped from 87 percent in 1994 to 43 percent
in 2000. In the same time frame, the number of accredited anesthesiology
programs decreased substantially.
It is no wonder, then, that the number of actively practicing
anesthesiologists in the United States is increasing at a snail's
pace. Government and American Medical Association (AMA) statistics
indicate a substantial slowing of the growth rate of anesthesiologists’
labor supply from approximately 3.6 percent in the early 1990s
to 0.6 percent during 1998. 1,2
This sluggish growth rate is echoed in the membership growth rate
of ASA, with only 256 new active members added in 1999. Simultaneously,
advances in surgical health care and an aging population ensured
a substantive increase in operative procedures. The number of
people in the United States over 65 increased by 11 percent in
this time period, and those above age 85 increased by an astounding
34 percent! The inpatient procedure rate in the elderly population
is approximately three times that of the general population (4,469
versus 1,519 per 10,000 population). 3
As a result of such powerful trends, operative procedures have
increased substantially and have grown out of proportion to the
increase in active anesthesiologists.
Where do we stand now?
A curtailed supply of anesthesiologists and the ever-growing
demand for surgical health care have brought about the current
national anesthesiologist shortage. We have attempted to quantify
this shortage and predict the extent of the shortfall over the
next five years.
In order to quantify current supply and demand, we assembled
information about the requirements for anesthesiologists during
the past decade from several sources. The workforce was estimated
using published health demographic data from federal agencies
and AMA as well as membership data from ASA. Federal statistics
on the number of practicing anesthesiologists are only available
until 1998; we estimated anesthesiologist supply in 2001 based
on the number of graduating residents and fellows, adjusting for
trainees with J-1 status.
We assumed that neither a shortage nor an oversupply existed
in 1994. Demand for anesthesiologists was indicated by the number
of inpatient nonfederal, short-stay hospital procedures reported
by federal agencies. We extrapolated demand using a hypothetical
2 percent or 3 percent yearly growth rate after reviewing procedure
growth rates in the mid 1990s, procedure rates for the elderly
and population aging trends.
We based our estimate of anesthesiologist supply for 2001-03
on the estimated current supply and by the projected graduation
rates of residents currently in training. We assumed that the
attrition rate during residency, recently estimated to exceed
10 percent, would decline to its historical level of 3 percent
over the next five years. 4. We reasoned
that the number of pain fellows trained each year will not increase
from current levels and that about half will be available to provide
anesthesia care. Each year after, AMGs were assumed to increase
by 15 percent and international medical graduates (IMGs) to remain
at 500 trained each year.
We believe the fraction of female anesthesiologists in the labor
force will grow by about 1 percent each year, which approximates
the gender composition of current medical school classes. A proportion
of this component of the labor force may be lost because of part-time
status.5 Currently, women account
for about 20 percent of ASA members, 28.6 percent of all anesthesiology
residents in 1999 6 and 46 percent
of entering medical students in 2000. 7
We estimated retirement rates based on the assumption that anesthesiologists
will generally retire at age 65 and on the age distribution of
active ASA membership, which shows that loss due to retirement
will increase from 300 per year currently to about 800 per year
in 10 years.
Our model [Figure 1] indicates
a current 4- to 12- percent shortage of anesthesiologists, depending
on the assumption of a 2- or 3-percent increase in annual demand.
The current shortfall amounts to approximately 1,400- 4,000 anesthesiologists
nationwide. If demand continues, the shortfall could increase
to 9-22 percent by 2005, representing a shortage of at least 3,500
and as many as 7,900 anesthesiologists.
Are these estimates reasonable?
A survey conducted last fall by the Massachusetts Society of
Anesthesiologists found 16 of the 55 responding anesthesia departments
delayed elective surgery due to worker shortages, while eight
had delayed urgent and emergent surgery. Twenty-one departments
had limited or discontinued pain management services. Eighty percent
of departments were recruiting, with a total of 86 vacant positions,
of which 90 percent had been vacant for more than a year. In Massachusetts,
a 10 percent shortage has been estimated, which would amount to
about 3,500 anesthesiologists when extrapolated nationwide.
Anesthesiology position advertisements in Anesthesiology have
increased from 42 monthly in 1995 to 137 per month in 2000. A
survey of academic anesthesiology departments conducted by the
Society of Academic Anesthesiology Chairs (SAAC) and the Association
of Anesthesiology Program Directors last August showed an average
of 3.8 anesthesiologist and 4.0 nurse anesthetist positions vacant
per department alone; this translated into a combined deficiency
of nearly 900 positions in academic departments. 8
Since academic anesthesiologists make up less than 25 percent
of the total workforce, an estimate of the total shortage of 2,000-2,500
based on the SAAC data might be reasonable.
Extenders, such as nurse anesthetists and anesthesiologists’
assistants, are seen by some as a remedy for the shortage. We
see this as unlikely for the following reasons. Nursing as a profession
is experiencing increasing difficulties with recruitment. Nurse
anesthesia programs have decreased, and the proportion of nurse
anesthetists close to retirement age is increasing. Of all nonphysician
clinicians studied, nurse anesthetists were the only group projected
to decline in the next two decades. 9
Anesthesiologists assistants are only a small group and still
labor under licensing issues and a dearth of training programs.
Our model indicates that the cumulative shortage of anesthesiologists
is now 1,400-4,000, depending on assumptions about growth. Based
on the supporting information discussed, these estimates are likely
to bracket the “true shortage.
Several factors could change this analysis. These include the
potential limitation of growth in surgical activity from lack
of personnel (anesthesia and other providers), changes in economic
climate that could decrease demand for certain elective surgery,
and global changes in the health care environment limiting access
to surgical procedures otherwise referred to as rationing.
Where do we go from here?
Our analysis of the current supply and demand of anesthesiologists
led us to conclude that the present short supply of anesthesiologists
will continue well into the next decade. It supports the notion
of a protracted shortfall of anesthesia providers so aptly portrayed
in a recent ASA NEWSLETTER editorial. 10
Data from the National Resident Matching Program indicate that
more physicians will become available during the next five to
10 years. Since physicians work more hours per week and provide
a wider variety of services (e.g., pain management, intensive
care, postoperative care), it is anticipated that physician anesthesiologists
will predominate in the anesthesia workforce in the foreseeable
future.
Given the dramatic market forces in anesthesia worker supply,
economic incentives alone should draw significant numbers of AMG
applicants to anesthesiology. We need to encourage the best and
brightest medical students to choose our specialty. We need to
embrace the diversity offered by interested and qualified IMGs
in pursuing anesthesiology training. We need to examine the number
of anesthesiology training positions to ensure that anesthesiologists
will continue to meet the astounding needs of our growing elderly
population. Based on the anesthesiologist workforce model we have
developed, we project a need to graduate more than three times
the number of current residents by 2005 to keep up with demand
for and attrition of anesthesiologists!
In conclusion, we see a current and sustained shortage of anesthesiologists.
Only by planning systematically for a steady, substantial and
sustainable rebound in anesthesiologist supply will we be able
to avoid another debacle of failed workforce predictions and supply-and-demand
imbalances that have so severely affected the lives of our colleagues
and leaders in anesthesiology.
References:
1. Number of Active Physicians (MDs) and Physician-To-
Population Ratios by Specialty, Selected Years 1970-1996. Table
202. In: United States Health Workforce Personnel Fact Book. Washington,
DC: US Dept. of Health Resources and Services Administration,
Bureau of Health Professions; 1999:24.
2. Physicians by Age and Specialty, 1998. Table
12. In: Physician characteristics and distribution in the U.S.
2000-01 Edition. Chicago, IL: American Medical Association; 2000:17.
3. National Center for Health Statistics. Advance
Data 316. National Hospital Discharge Survey: 1998 Sum mary. Accessed
June 29, 2001. Available at: www.cdc.gov/nchs/products/pubs/pubd/ad/311-320/ad316.htm
.
4. Grogono AW. Update on residency composition
1960-2000. ASA Newsl. 2000; 64(11):16-19.
5. Seinhauer J. For women in medicine, a road
to compromise, no perks. The New York Times. March 1, 1999; section
A:1.
6. Graduate Medical Education. Appendix II. JAMA.
2000; 284:1159-1172.
7. Cohen JJ. Valuing tomorrow’s doctors. AAMC
Reporter. 2000; 10:1-2.
8. Tremper KK, Gelman S. Surviving the perfect
storm: Challenges faced by our training programs. ASA Newsl.
2001; 65(2):22-24.
9. Cooper RA, Laud P, Dietrich CL. Current and
projected workforce of nonphysician clinicians. JAMA. 1998;
280(9):788-789.
10. Lema MJ. In case you haven’t heard…There
are no available anesthesia providers ASA Newsl. 2001;
65(2):1
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Gifford
Eckhout, M.D., is a Staff Anesthesiologist at the Cleveland
Clinic Foundation, Cleveland, Ohio. |
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Armin
Schubert, M.D., is Chair, Department of General Anesthesiology,
Cleveland Clinic Foundation, Cleveland, Ohio. |
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