ANESTHESIA WORKFORCE
The workforce for anesthesia services continues to undergo dramatic
change relating to its supply, diversity, and function. Historically an undersupplied
specialty, unable to meet clinical demands in even the OR, the specialty of anesthesiology
has grown rapidly since 1980.[34]
Diverse trends
account for this growth, including the increasing sophistication of anesthesia care,
itself related to the maturation of subspecialty surgery (e.g., transplantation,
cardiothoracic surgery, ambulatory care); increasing
Figure 2-3
The number of pain management programs in departments
of anesthesiology and the number of residents in these programs for the years 1993–2003.
(Data provided by the American Board of Anesthesiology.)
incomes of physician specialists; and a doubling of the number of U.S. medical students
graduating each year. Thus, anesthesiologists now work in sites well beyond the
OR, including sites outside the hospital, as discussed previously. Indeed, by 1990,
anesthesiologists devoted the majority of their professional time to recognized subspecialties
(e.g., ambulatory, cardiothoracic, obstetric, and pediatric anesthesia, critical
care medicine, and pain management). Clearly, anesthesiology has entered a period
of maturation if not sophistication in its professional development.
The growth in the supply of anesthesiologists (208% during the
period between 1975 and 2000, compared with 94% for the total physician supply[35]
)
has markedly altered the mix of anesthesia care providers. In the 1970s there were
two nurse anesthetists for every anesthesiologist[36]
;
by the later 1980s the two provider groups had equal numbers. In 1991, there were
about 21,000 nurse anesthetists and 25,000 anesthesiologists[36]
;
in 2000, there were 24,314 nurse anesthetists[37]
and 35,699 anesthesiologists.[35]
More than 500
anesthesiologists' assistants have also been trained since two training sites opened
in the early 1970s. These personnel are deployed in a highly variable array of configurations,
even in the same community, across the United States. Most anesthesia care is delivered
by an anesthesia care team composed of an anesthesiologist directing nurse anesthetists
and anesthesiology residents, with differing ratios among the provider types reflecting
the composition of the care delivered. However, in much of the western part of the
United States, anesthesiologists tend to provide direct care, without nurse anesthetists,
and in rural areas nurse anesthetists often work in the absence of anesthesiologists.
[34]
[36]
[38]
Overall, there is an almost six-fold variation in the per capita presence of anesthesiologists
across the United States ( Fig. 2-4
),
itself suggesting that there is no consensus on the optimal or appropriate mix of
anesthesia personnel.
As dramatic as these workforce changes have been, they constitute
merely a prelude to future changes. The marked growth in the supply of anesthesiologists
peaked by the mid-1990s, when the rate of production of new
Figure 2-4
The geographic distribution of anesthesiologists per
100,000 population, by hospital referral region in 1996, ranged from 4.3 (Harlingen,
Texas) to 25.5 (Hinsdale, Illinois). (From Wennberg and Cooper.[42]
Copyright, the Trustees of Dartmouth College, 1997.)
practitioners was about three times that of attrition.[34]
As a result, coupled with marketplace changes related to the accelerating growth
of managed care, graduates experienced difficulty finding jobs, medical students
shunned the specialty, and new trainee cohorts more closely approximated attrition
(perhaps 800 per year). Professional opportunities again seem adequate, but looming
on the horizon are diverse factors that are likely to alter the equilibrium if not
the practice of anesthesiology.
Among factors that may encourage more students to opt for anesthesiology
are the emerging recognition that the shortage of primary care physicians proclaimed
early in the decade was either quickly corrected or a forecasting error; further
expansion of the anesthesiologist's role and practice sites; and increasing amount
and sophistication of surgery for a graying population. As mentioned earlier, the
desire of medical students to train in specialties that permit a controllable lifestyle
must be appreciated. As an aside, it is interesting that, with the institution of
the 80-hour duty limits mandated by the Accreditation Council for Graduate Medical
Education (ACGME), general surgery programs have experienced an unprecedented increase
in applications. Certain factors may dissuade students from choosing anesthesiology
as a specialty. These include the continued political fight to alter Medicare regulations
(that are being adopted by private insurers), fostering independent practice by nurse
anesthetists; further decreases in federal support of graduate medical education,
especially specialist training; continued increases in students' already high loan
indebtedness coupled with potential reductions in anesthesiologists' income relative
to those of other specialties; new technology that makes some anesthesia services
appear so safe that non-anesthesia personnel may provide them (e.g., propofol sedation
[39]
); and possibly greater instability in professional
opportunities in an increasingly competitive health care marketplace. Thus, a grand
and most dynamic interplay among diverse factors—far more complex than merely
potential numbers of services to be provided and numbers of personnel being trained
and lost to attrition—will influence future anesthesia workforce requirements.
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