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Anesth Analg 2003;96:207-214 © 2003 International Anesthesia Research Society
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Abstract |
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Reports of anesthesia personnel shortages in 2001 led to the first comprehensive analysis of labor supply and demand for anesthesiologists since 1993. We now update this analysis and forecast, incorporating newly available data about residency composition, American Board of Anesthesiology and Certified Registered Nurse Anesthetist certification, the 2002 residency match, surgical facilities, and the US physician workforce. In addition, US residency programs were surveyed; national health care utilization and economic data were reviewed. Adjusted for the new information, our model still shows an anesthesiologist shortfall in 2002, projected to continue through 2005. We now estimate a current shortage of 1100–3800 anesthesiologists in 2002, on the basis of past service demand growth assumptions of 2%–3%, respectively. By 2005 this number is expected to be 500–3900, depending on a future service demand growth of 1.5%–2%, respectively. To avoid a surplus of anesthesiologists in 2006–2010, our model suggests that the number of graduates should level out at 1600 yearly, with a 1.5% service demand growth. To forecast the anesthesia personnel market more accurately, thereby helping supply match demand, substantially better quantification of future demand for anesthesia services is needed. If sustained growth in service demand >1.5% is likely, entry into the specialty should be encouraged beyond the current level.
IMPLICATIONS: With updates from training programs, surgical activity, and other sources, our previously described model estimates a continuing shortfall of 1000–3800 anesthesiologists in 2002 and 500–3900 in 2005, assuming that service demand growth is 1.5% or 2% annually. If service growth >1.5% is likely, entry into the specialty should be encouraged beyond current levels.
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Introduction |
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We previously published an assessment of anesthesia personnel supply and demand during the years 1993–2001 and modeled the market for anesthesiologists in future years (1). This was the first comprehensive assessment of the anesthesia personnel market since the 1993 Abt consultant report commissioned by the American Society of Anesthesiologists (ASA) (2). One of the conclusions was that the current shortage exists in part because inaccurate information reached medical students and those advising about entry into anesthesiology residency training.
New developments since our 2001 report may affect anesthesia personnel markets. Furthermore, additional data about resident entry and visa status, a determinant of workforce availability, have become available. This includes a survey recently conducted by the Society of Academic Anesthesiology Chairs/Association of Academic Program Directors (SAAC/AAPD).
Physician workforce planning based on units of work and full-time equivalent has had a poor track record, whereas approaches incorporating trends such as economics, population growth, physician work effort, and nonphysician substitution have been more successful (2,3). The purpose of this article is to update and refine our previous trend model and forecast of the anesthesia personnel market.
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Methods |
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We analyzed newly available residency graduation data (4), National Resident Matching Program results (5), physician workforce data, and certification rates of nurse anesthetists (NAs). In addition, an e-mail and phone follow-up survey was conducted of all the training programs listed on the SAAC/AAPD Web site (6). Program directors were requested to fill out a survey via a return e-mail or fax (Appendix 1). Nonrespondents were e-mailed again in 2 wk. Remaining nonrespondents were called to obtain the information by phone. To update our assumptions about the demand for anesthesia services, we reviewed national health care utilization, as well as operating facility (National Center for Health Statistics: unpublished data from the national hospital discharge survey 2000 [courtesy of Lola Jean Kozak, PhD, Hospital Statistics Branch, NCHS]) (7–13) and economic data.
Information from these sources was synthesized and the model updated. The new predictions for personnel shortfall and residency training slot expansion are provided and compared with those previously reported. As before, the shortfall of anesthesiologists is reported as a percentage of supply.
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Results |
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The results of the SAAC/AAPD survey of US anesthesia residency programs appear in Table 1. For 2002, 1290 third-year clinical anesthesia (CA-3) residents will graduate according to the survey, compared with our assumption of 1309. The difference is easily accounted for by nonresponding programs and programs with incomplete data. The preliminary results of the 2002 anesthesiology residency match showed that only 24 of 125 participating residency programs failed to match 100% (5). Of 392 postgraduate year 1 and 777 postgraduate year 2 positions offered, only 17 and 40 were unfilled in the match, respectively. Figure 1 shows how these statistics have behaved during the last 5 yr. The number of residents recruited via the match increased by 14% this year, compared with 2001, which is consistent with the assumptions about entry rates in our model.
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According to the survey, approximately 142 CA-3 residents hold J-1 visas that do not allow them to enter the workforce. Because our prior estimate was 227, we underestimated the number of graduates available to the workforce in 2002 by approximately 75, in part because we overestimated the total number of international medical graduates (IMG) CA-3 residents by approximately 60 [compared with Grogono’s (4) numbers], on the basis of data available for the same cohort in the preceding year. A greater attrition rate among IMGs compared with American medical graduates (AMG) residents may have accounted for this.
Although J-1 visa holders are required to live abroad after completing training before being eligible for a US work visa, use of waiver programs increases the availability of these IMGs to the workforce. States and federal agencies have the authority to waive the requirement for J-1 visa holders to return to their home countries for 2 yr before applying for a work permit. Arkansas, Connecticut, Ohio, Vermont, Indiana, and Kentucky have allowed processing of J-1 visa waivers for anesthesiologists after ascertaining that the year’s allotment has not been fully used by primary care specialties. Although these waiver programs were originally intended only for primary care specialties, anesthesiologists have made convincing arguments that there is a critical shortage, and states have responded by granting waivers in underserved areas. As other shortage specialties make use of this pathway, the opportunity to bring more fully trained anesthesiologists into the workforce may diminish (Leopold & Associates, Cleveland, Ohio, personal communication, June 27, 2002; this has already occurred in Ohio for the 2002 quota allocation). This trend may be offset if the recently approved increase in the waiver quota became law (14).
Improved availability of J-1 visa waivers will result in a growing fraction of J-1 visa holders entering the US anesthesiologist workforce. In addition, an unknown number of J-1 visa holders may reenter the US labor market after having lived abroad for 2 yr. If all J-1 visa-holding anesthesiology residents were to be granted work permits from now on, our model would underestimate the total number of graduates available to the workforce by approximately 150 until 2004 and by 125 each year thereafter.
Our model was revised to account for visa waiver availability, as well as for an overall decrease in J-1 visa holders among anesthesia residents. It continues to assume conservatively that approximately 90% of IMGs stay in this country to practice, compared with 80% in the Cooper et al. (3) workforce trend model for US physicians.
The Education Commission for Foreign Medical Graduates has considered ceasing to sponsor J-1 visas for individuals in fellowships not independently accredited by the Accreditation Council of Graduate Medical Education (ACGME) (15). The effect should be a decreasing fill rate for non-ACGME-accredited fellowships and a corresponding increase in fill rates for ACGME-accredited fellowship programs as J-1 visa holders are forced to seek alternatives. Our prior analysis assumed that entry rates into fellowship positions, and the resultant entry delay into the workforce, would remain constant (1). Residents are choosing advanced training (and delaying workforce entry) with approximately the same frequency as the year before (530 versus 519, respectively), which is still consistent with the assumptions of our model. As seen from Table 1, nearly a third of all fellows held J-1 visas. Because J-1 visa holders are decreasing rapidly among CA-1s, CA-2s, and CA-3s in residency programs, and because employment opportunities abound for graduating CA-3s, fellowship entry rates are likely to decline during the next 2–4 yr. Academic medical centers that have come to depend on fellows to help with education and, in some instances, patient care, will be most affected. Although having fewer fellows might temporarily augment the total anesthesiologist workforce, we believe that there will not be a substantive effect on the aggregate US anesthesiologist personnel supply.
Physician productivity is not seen as increasing, because of early retirement and an increasing proportion of female practitioners (3). The economic slowdown and associated collapse in the equities market has adversely affected the retirement savings of senior practicing anesthesiologists. It is unclear how many have delayed their retirement or opted for part-time work instead of retirement as a result. Therefore, we have not included this possible effect on manpower in our analysis.
Female participation in the anesthesiology workforce has not grown substantially in recent years (16). However, high entry rates from US medical schools into the specialty suggest that the participation of female anesthesiologists who seek part-time positions at a more frequent rate than their male counterparts (17,18) will soon increase. As before, our model assumes a 10% reduction in the workforce contribution from women.
Of note is the accelerating number of anesthetizing locations both in hospitals and free-standing outpatient surgery centers (FOSCs) (Tables 2 and 3). This likely has further reduced the productivity of anesthesiologists, contrary to the assumption by Abt & Associates (2).
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On November 13, 2001, the Centers for Medicare and Medicaid Services issued its final rule retaining the federal requirement that NAs be supervised by a physician in all Medicare-approved hospitals and ambulatory surgical centers. The rule allows state governors to opt out, reverting supervision of NA practice to individual state law. Although five states (19) have opted out, only New Hampshire state law actually permits the independent practice of anesthesia by NAs. Although the opt-out provision potentially lowers entry barriers for nonphysician anesthesia providers into anesthesia labor markets (Table 4), its national influence is, at present, miniscule. Enrollment in NA schools has increased recently, with 1159 graduates in 2001, and this is projected to increase further to 1361 in 2002 and to 1534 in 2003 (Paul Blakely, Council on Certification of Nurse Anesthetists, personal communication, July 19, 2002). This increase may help to alleviate shortages, but it is also needed to offset the substantial retirement rates anticipated among NAs, as well as the declining work effort of those approaching retirement (20,21).
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Our current and future estimates of demand for anesthesiologists were primarily based on data from the National Center for Health Statistics, which showed a 5%–6% increase in outpatient surgical procedures and a 0.3% increase in inpatient hospital procedures during the period of 1990–1998. The most recent federal data (7) indicate continued stagnation in inpatient procedures but indicate a 1.5% increase in procedures for patients 65 yr and older, from 15,240,000 in 1998 to 15,467,000 in 1999. The American Hospital Association (AHA) inpatient surgical volume also did not change from 1998 to 2000, but it increased by 2% from 1999 to 2000 (Table 2). Anecdotal reports suggest that hospital surgery volume may be increasing (22). AHA outpatient procedure volume (not including FOSCs) indicates that the rapid growth rates of the mid 1990s have slowed somewhat, but it supports a 2%–3% annual growth estimate by extrapolation. Demand for anesthesiologists is related as much to case volume as it is to the number of operating locations and facilities requiring coverage. According to data from the SMG Marketing Group, FOSCs have increased from 1860 in 1994 to 3383 in 2002, with the growth rate in the last 2 yr exceeding 11% (Table 3). In these new figures, we see a confirmation that demand for anesthesia personnel is still increasing at a 1.5%–2% overall yearly growth rate, as previously assumed in our model.
Gross Domestic Product (GDP) is associated with physician demand on a long-term basis (3). Demand for anesthesiology care was likely affected by the general economic downturn already in progress before the tragic terrorist attack on the World Trade Center on September 11, 2001, and now thought to be more profound than previously reported (23). These developments affected discretionary health care spending adversely, a category in which some elective surgery undoubtedly occurs. Continuing GDP growth at a high level is uncertain given investor concern over the financial conditions in private industry. The overall effect of recent economic developments on demand for anesthesiology services was therefore likely negative (Table 4), although arguably transient.
New data specific to the demand for anesthesia services are not yet available, but some centers catering to discretionary surgery, such as certain plastic, ophthalmic, and infertility surgeries, are seeing a flattening of demand. International surgical patients, especially those from the Middle East, are no longer strongly contributing to the demand for anesthesiologists. At the first author’s institution, inpatient hospital discharges of international patients, 90% of whom are surgical, decreased >50% in the 3 mo after September 11, 2001, compared with the previous year (C. Simpfendorfer, MD, Cleveland Clinic International Center, personal communication, April 4, 2002 and August 6, 2002). Nine months after the terrorist attacks, international surgical volume recovered to within 70% of the level before September 2001. Although substantial, this effect is expected to be transient and reverse within 12–18 mo. Cardiac surgical volume is also perceived to be decreased approximately 10% across the nation (T. Cosgrove, MD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, personal communication, April 9, 2002).
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Discussion |
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New data from the last 12 months indicate that our predictions for the intermediate term (2004–2005) overestimated the total number of graduates by approximately 3%, underestimated the number of AMGs entering the specialty by approximately 4%, and overestimated the loss to the workforce from IMGs holding J-1 visas. In particular, beginning with 2004, the proportion of IMG to AMG residency graduates is smaller than previously assumed (33% versus 38%) and declines further to 27% in 2005, and the number of J-1 visa holders begins to be insignificant. In all, this means that we underestimated the available graduates for 2004–2005 by 50–60.
For 2001, the number of graduating residents reported by Grogono (4) was 1078, compared with our assumption of 1017, an underestimate of current supply by approximately 60. Because our estimate was based on previously reported numbers of CA-2 residents, the difference must have resulted from a smaller attrition rate or reentry of residents on leave of absence. Similar considerations may apply to the present CA-3 class. The SAAC/AAPD survey identifies 1290 residents in training, compared with 1253 in Grogono’s report (4). Conducted toward the end of 2001, the survey represents more recent information than Grogono’s data, which were published in November 2001.
On the basis of the information available, our model has been adjusted to incorporate a lower ceiling of 1600 total graduates. In addition to correcting the model for the above known updates in residency composition, we also decreased the fraction of IMG residents holding J-1 visas from 25% to 20%. On the demand side, we have accounted for the extraordinary events of September 11, 2001, and the economic slowdown with a reduction in demand for growth in anesthesia services by 0.5% in 2001 and 2002.
Adjusted for the new information available since last summer, our model still identifies a shortfall of anesthesiologists in 2002, which is projected to continue through 2005 if the smaller 1.5% yearly growth rate is assumed (excepting 2001 and 2002). This is consistent with continuing reports of operating room closures (24,25) and widespread shortages of anesthesiologists. Under a larger growth assumption (2%), the deficit of anesthesiologists continues at approximately the same level through 2015. Our new estimates are that there is a continuing current 3.2%–11.0% shortage of anesthesiologists in 2002 (Table 5), depending on whether 1.5% or 2% growth is assumed. From a survey of hospital administrators conducted by the ASA during the second quarter of 2002, a minimum of 1400 positions for anesthesiologists were available in hospitals with 100 beds alone (http://www. asahq.org/Washington/TarranceSummaryData. pdf). This estimate is 5%–15% smaller than our previous one (1). By 2005, the shortage is expected to be 1.1%–10.4% of the anesthesiology workforce. To avoid a surplus of anesthesiologists in the years 2006–2010 with 1.5% service demand growth, our model suggests a training output of 1600 graduates annually.
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The range of this forecast is heavily dependent on the prediction of growth in demand for anesthesia services. To forecast the personnel market accurately and avoid wide gyrations in supply, it is therefore critical to study and quantify the future demand for anesthesiology services. If sustained growth in excess of 1.5% is likely, entry into the specialty should continue to be encouraged. If growth is sustained at
1.5%, beginning with next year’s residency applicants, a note of caution should be sounded. The existing anesthesia personnel shortage has inflicted substantive damage to the specialty, as is evident from the loss of many fine teachers and investigators from academic anesthesiology to private practice or industry and a talent diversion of medical students to other medical specialties. There is concern over this issue in organized medicine. An ASA task force on graduate medical education has been convened to address possible solutions. Likewise, the leadership of SAAC/AAPD is conducting a follow-up analysis to their 2000 assessment of academic personnel supply and demand. The Association of American Medical Colleges is also planning a comprehensive review of factors that affect the demand for and productivity of all physicians (26).
Accurate and up-to-date information affecting both personnel supply and health care demand is required to predict workforce needs. Accurate demand data currently available from credible sources are generally two or three years old when they become available. For example, the most recent federal inpatient procedure data were available for the year 1999, whereas federal outpatient procedure data were available only for 1996. Only recently has the AHA begun providing near real-time patient volume and facility data about the number of FOSCs, a substantial source of demand for anesthesia personnel (9).
A meaningful anesthesia workforce analysis, then, needs to be based less on historical data and more on information that reflects the ever-changing health care environment. Our updated view of the anesthesia personnel shortfall emphasizes this point, because a number of new developments have surfaced even in as short a period of time as 12 months, including the events of September 11, greater use of visa waivers by fully trained IMGs, a formalized limitation of resident work hours, a federal decision regarding independent practice of NAs, and escalating malpractice expense (Table 4). This dynamic picture suggests that a continuing analytical process to better address personnel needs be developed.
A truly optimal approach requires the establishment of an independent, well-respected standing professional entity, with representation from academic practice, private practice, and government, assisted by appropriate consultants, whose function it is to conduct and publicize specialty-specific up-to-date workforce balance analyses. Providing authoritative, forward-looking, continually updated anesthesia personnel supply and, especially, workforce demand data to medical students and those advising on career decisions in anesthesia may go a long way to prevent labor market imbalances detrimental to the specialty as well as to the general health care needs of the American public. Such an approach will likely require close collaboration among organizations such as the ASA, the American Medical Association, and the Association of American Medical Colleges.
Appendix 1. Text of J-1 Visa Resident Survey E-Mailed to SAAC/AAPD Membership
To estimate how many graduates of each year’s class will be available to enter the U.S. job market we need to know how many residents are in each program by year who are on J-1 Visas. Please fill out the following survey. This is very important for your specialtyl We will provide the information from this nationwide survey to you. Thank you for taking the time out to complete this.
Please reply by following the directions below:
- Select "Reply" to this e-mail message.
- Scroll down and answer the questions by clicking in between the parenthesis. Please enter a number (including zeros) into every area. If you choose not to answer the question please enter NA in the space.
- Send/Return this email to me.
Institution:
How many total residents do you have? ( )
Resident Breakdown by Year
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References |
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- Schubert A, Eckhout G, Cooperider T, Kuhel A. Evidence of a current and lasting national anesthesia personnel shortfall: scope and implications. Mayo Clin Proc 2001; 76: 995–1010.[Abstract]
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- Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff Millwood 2002; 21: 140–54.
[Abstract/Free Full Text] - Grogono AW. Residency composition and numbers graduating from residencies and nurse anesthesia schools. ASA Newslett 2001; 65 (11): 19–23.
- Grogono AW. National residency matching program results for 2002: excellent results for anesthesiology. ASA Newslett 2002; 66 (5): 3–18.
- Web site for the Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors: http://www.asahq.org/aapd-saac./
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- American Hospital Association annual surveys, 1991 through 2000. Health Forum, LLC, 2002.
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- House approves J-1 visa waiver expansion: Washington highlights. June 28, 2002. Available at: http://www.aamc.org/advocacy/library/washhigh/2002/062802/_3.htm. Accessed: June 28, 2002.
- J-1 Sponsorship in subspecialty programs not independently accredited by ACGME ("non-standard programs"). Available at: http://www.ecfmg.org/evsp/evspnews.html. Accessed: February 28, 2002.
- Calmes SH. Anesthesiology demographics: woman physicians’ changing specialty choices and implications for anesthesiology’s workforce shortage. ASA Newslett 2001;65(8). Available at: http://www.asahq.org/NEWSLETTERS/2001/8_01/new0801. html. Accessed: October 16, 2002.
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[Abstract/Free Full Text] - Steinhauer J. For women in medicine, a road to compromise, not perks. The New York Times. March 1, 1999:A1, 1.
- Turpin SD. New Hampshire opts out of federal supervision requirement. ASA Newslett 2002; 66 (7): 28.
- Nursing school enrollments decline as demand for RNs continues to climb (news release). Washington, DC: American Association of College of Nursing Media Relations, February 17, 2000. Available at: http://www.aacn.nche.edu/Media/NewsReleases/2000feb17.htm. Accessed: August 16, 2001.
- Rosenbach ML, Cromwell J, Pope GC, et al. Report of the national commission on nurse anesthesia education: study of nurse anesthesia manpower needs. AANA J 1991; 59: 233–40.[Medline]
- Abelson R. Patients surge and hospitals hunt for beds. The New York Times. March 28, 2002:A1, 1.
- Heffler S, Smith S, Won G, et al. Health spending projections for 2001–2011: the latest outlook—faster health spending growth and a slowing economy drive the health spending projection for 2001 up sharply. Health Aff Millwood 2002; 21: 207–18.
[Abstract/Free Full Text] - Bonfield T. Anesthesiologists in short supply: hospitals say some leave for more money. The Cincinnati Enquirer. July 27, 2001. Available at: http://enquirer.com/editions/2001/07/27/loc_anesthesiologists_in.html. Accessed: October 16, 2002.
- Musumechi RJ. Medicare and the anesthesia shortage: increasing our chances for survival. ASA Newslett 2002; 66 (3): 21–2.
- Snyderman R, Sheldon GF, Bischoff TA. Gauging supply and demand: the challenging quest to predict the future physician workforce. Health Aff Millwood 2002; 21: 167–8.
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