“I hear that the training programs are awash with applications from the best and brightest medical students! It won’t be long before there’s another glut of anesthesiologists on the market…” This comment, heard at the January ASA Conference on Practice Management in Florida, contrasted sharply with other anesthesiologists who bemoaned the dearth of physicians available to work in their locale. What’s going on here? After all the articles and opinions, how is it that our members still are not sure what is happening in the market?

In 2000, when Armin Schubert, M.D., asked me to help on a “small” study of anesthesiology workforce needs, I did not know that we would be diving into an extremely complicated and controversial area for our specialty. After all, the previous workforce report from Abt Associates¹ had not predicted the “oversupply” of anesthesiologists in the mid-1990s or the subsequent “undersupply” that became apparent by the end of the decade. Our first report² in 2001 quantified an existing shortage of 1,200 to 3,800 anesthesiologists. An update on this estimate published last year³ confirmed the ongoing personnel shortage. Alan W. Grogono, M.D., in his annual review of residency programs,⁴ commented that the studies were underestimating the existing and future anesthesiologist workforce. The growth in resident numbers that we had assumed in the research forecasts has not materialized. In fact the 2003 PGY-1 anesthesiology class is smaller than the previous year’s class by 128 positions! These facts, in combination with higher growth in demand for services and ongoing attrition in the workforce from retirements, lead me to believe that this shortage is still very real and persistent.

So what? As one anesthesiologist said: “Shortages are good for us. We have lots of opportunities, salaries are high and hospitals cater to us for fear of losing our services. Let’s keep it this way!” In one sense, this is understandable. I appreciate getting calls from recruiters with promises of riches to be had. It is always a fun item to bring into your next meeting with the hospital administrator! But one should consider the unintended consequences of severe personnel shortages.

Shortages stress the current workforce through longer working hours, curtailed vacations and time out of the operating room. In a free market, shortages (both physician and nonphysician) drive up the cost of labor dramatically and change the economics of the market. Direct patient care revenues in many instances no longer cover the actual labor costs of providing the service. In these cases, the additional monies may be found in the deep pocket of the hospital. A recent survey by the Society of Academic Anesthesiology Chairs⁵ demonstrated an increase in institutional support per full-time equivalent faculty from $34,000 in the year 2000 to $104,000 in 2003. Increasing financial burdens such as these make anesthesiology groups much more dependent on hospitals and may prompt a hospital CEO to search for a lower-cost alternative to the current providers through a new request for proposal.

Where is all the demand for anesthesia services coming from? The surgical literature has shown that our colleagues also anticipate ever-increasing workloads. Etzioni6 studied the impact of an aging population on demand for surgical services. He assumed that the rates of surgical procedures within different age groups would remain constant. His model predicts a 14-percent increase in surgical volume by 2010 and a 47-percent increase by 2020. This increase in volume, along with greater numbers of procedures done in remote locations and freestanding surgical centers,³ supports the notion that demand for anesthesia services will continue to grow.

If hospitals and patients are consumers, how can they cope with personnel shortages? After all, alternative providers in anesthesia care do exist. There are usually others who argue that they can provide equivalent services for less money. Perhaps this would involve anesthesiologists directly out of training who are willing to work hard for what to them is a significant amount of money. Perhaps the alternative is an anesthesiologist with lesser credentials than the existing ones. Another substitution that may be equivalent in the minds of the average administrator is greater reliance on nonphysician providers. This substitution mindset can only be overcome with a lot of education by the medical staff, if they have the ear of the administration.

Businesses often use a “SWOT” (strength, weakness, opportunity, threat) analysis to get an idea of where they stand in the marketplace. For our specialty, it might look like this:

Strength

• Anesthesiology is the practice of medicine.
  
  
• Anesthesiologists are the best due to our training and experience.
  
  
• We willingly work long hours.
  
  
• We train the best and brightest medical students in anesthesiology.

Weakness

• Few nonphysicians realize that anesthesiology is the practice of medicine.
  
  
• Few people know who we are much less that we are the best.
  
  
• No one can work long hours forever, especially inexpensively.
  
  
• The next generation of physicians will not work as hard due to lifestyle expectations.
  
  
• It is hard to educate and train anyone when you are short-staffed.
  
  
• Research and education are put on the back burner secondary to heavier clinical duties.

Opportunity

• Personnel shortages allow for increased bargaining power with insurers and hospitals.
  
  
• It is easier to get the dean’s or hospital CEO’s attention about money.
  
  
• The specialty is getting applications from the top medical students.
  
  
• Academic anesthesiology can rely on increasing amounts of financial support from the institution to increase research activity.

Threat

• The administrators writing stipend checks do not do it for the fun of it.
  
  
• As a specialty, we may become dependent on nonpatient care revenues to support our practice.
  
  
• The person who controls the dollars calls the shots.
  
  
• We could lose control of our practices.
  
  
• Resources are diverted from needed activities such as research and education.

As a specialty, anesthesiology has stood out from the crowd in the advances we have made in patient safety. We should be proud of our success and ever vigilant for outside forces that threaten to erode the practice of anesthesiology as the practice of medicine. Ongoing and severe shortages in our specialty may facilitate the substitution of less qualified providers in providing anesthesia care to our patients.


References:

1. Estimation of Physician Work Force Requirements in Anesthesiology. Bethesda, MD: Abt Associates Inc; 1994.

2. Schubert A, Eckhout G, Cooperider T, Kuhel, A. Evidence of a Current and Lasting Anesthesia Personnel Shortfall: Scope and Implications. Mayo Clinic Proceedings. 2001; 76: 995-1010.

3. Schubert A, Eckhout G, Tremper KK, An updated view of the national anesthesia personnel shortfall. Anesth Analg. 2003; 96:207-214.

4. Grogono AW. Resident numbers and total graduating from residencies and nurse anesthesia schools in 2003: Continuing shortages expected. ASA Newsl. 2003; 67(11):16-21.

5. <www.aapd-saac.org/meetingpapers/2003/tremper.pdf>. Accessed on March 19, 2004.

6. Etzioni D, Liu J. The aging population and its impact on the surgery workforce. Ann Surg. 2003, 238(2):170-177.

Gifford V. Eckhout, Jr., M.D., is a staff anesthesiologist at the Cleveland Clinic Foundation, Cleveland, Ohio. He is President-Elect of the Ohio Society of Anesthesiologists.