Anesth Analg 2004;99:1185-1192
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000135410.51921.14
ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH
Ronald D. Miller Section Editor
Faculty and Finances of United States Anesthesiology Training Programs: 2002–2003
Kevin K. Tremper, PhD MD*,
Amy Shanks, MS*,
Michelle Sliwinski, MS*,
Steven J. Barker, PhD MD ,
Roberta Hines, MD , and
Alan R. Tait, PhD*
*Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan;
Department of Anesthesiology, University of Arizona, Tucson, Arizona; and
Department of Anesthesiology, Yale University, New Haven, Connecticut
Address correspondence and reprint requests to Kevin K. Tremper, PhD, MD, Robert B. Sweet Professor and Chair, University of Michigan, Department of Anesthesiology, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Address email to ktremper{at}umich.edu
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Abstract
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Between February, 2000 and August, 2002 three surveys have been submitted to the program directors of the anesthesiology training programs in the United States (U.S.) to assess the departments’ needs for faculty and financial support from their institutions. In this article we present the results of a fourth follow-up survey. This survey also asked questions regarding the need for additional support to meet the new 80-h workweek resident requirement and asked the average academic time offered to faculty. The average department has 40 faculty members with 3.7 open faculty positions in the 78% of departments with open positions. Only 25% of the departments planned to add personnel to comply with the 80-h resident workweek. Fifty-one percent of the departments had a positive financial margin of $15,908/full-time equivalent (FTE) faculty anesthesiologist (faculty FTE), whereas 34% had a negative margin of $42,603/faculty FTE. The overall institutional support was $85,607/faculty FTE, which is a 43% increase over the previous year. The average academic time provided to faculty was 13.8%, a decline from 20% in 2000. Twenty-five percent of departments have closed an anesthetizing location as a result of a lack of faculty in 2003. Open faculty positions in U.S. training programs have remained fairly constant at 8% to 10% from 2000 to 2003. Institutional support for training departments has more than doubled since 2000, reaching approximately $85,000/faculty in 2003.
IMPLICATIONS: Open faculty positions in United States training programs have remained fairly constant at 8% to 10% from 2000 to 2003. Institutional support for training departments has more than doubled since 2000, reaching approximately $85,000/faculty in 2003.
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Introduction
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The past decade has seen dramatic swings in the number of medical students entering anesthesiology training programs in the United States (U.S.) (1). Because of a real or perceived excess of anesthesiologists in this country, there was a substantial decline in resident class size in the mid-1990s. The graduating class size decreased from 1796 in 1995 to 934 in 2000 (1,2). This reduction in practitioners entering the U.S. anesthesiology workforce has resulted in a nationwide shortage that may last more than 5 years (2–4). The decrease in supply of anesthesiologists has caused a significant increase in demand and salaries in both private practice and in teaching departments (2003 Society of Academic Anesthesiology Chairs Salary Survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, 2003) (5,6). The resulting competitive salary environment has acutely affected the finances of academic training departments (2). As faculty salaries have increased, academic departments’ finances have been compromised, placing in jeopardy their ability to train more residents and to conduct an academic program (2,7). In the year 2000, a committee of the Society of Academic Anesthesiology Chairs and Association of Anesthesiology Program Directors (SAAC/AAPD) produced a white paper that reviewed the financial and workforce problems facing anesthesiology training programs in the U.S. (2,7,8). A portion of this white paper included a comprehensive survey of the U.S. training departments to determine the current status of faculty and finances in the year 2000. Follow-up surveys were conducted in 2001 and 2002 to determine the trends with respect to workforce needs and financial status (2,3). The purpose of this current article is to report the results of the most recent follow-up survey and to compare these data with that of the 3 previous years.
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Methods
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For the past 4 years, e-mail surveys have been sent to the program directors of the U.S. anesthesiology training programs (2). The follow-up surveys conducted in 2001, 2002, and 2003 have focused on workforce needs: open faculty positions and open Certified Registered Nurse Anesthetist (CRNA) positions, departmental financial margins, and the amount of institutional support received. This current survey, distributed in August of 2003, also included questions regarding support for resident salaries and questions relating to anesthesia practitioners that were added as a result of the recently implemented Accreditation Council of Graduate Medical Education (ACGME) resident 80-h workweek (9). Additionally, program directors were asked the percentage of nonclinical time provided to faculty. (APPENDIX I) The email survey was sent in August; email reminders were sent every 2 weeks for the next 8 weeks to those who did not respond. In October of 2003, an additional email survey was distributed that asked if the departments had closed anesthetizing locations as a result of a lack of faculty or CRNAs and what was their anesthesia unit charge. (APPENDIX II) This survey was redistributed by email to all program directors and then weekly for the next 2 weeks to the nonresponders.
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Results
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The survey in Appendix I was distributed by email to 135 SAAC/AAPD program directors. An overall response rate of 65% (n = 88) was achieved. The results are presented in Tables 1–5. The average department has 40 faculty and 39 residents. For the 90% (n = 78) who have CRNAs, departments employ an average of 26. Seventy-eight percent of departments have an average of 3.7 open faculty positions whereas 21% (n = 18) of departments have no open positions. Overall, departments provided faculty with 13.8% nonclinical time where 1 day per week is considered 20%. For the departments who have CRNAs, 64% (n = 56) have an average of 3.9 open positions (Table 2).
Twenty-five percent of the departments anticipate recruiting new personnel to comply with the ACGME mandates for resident work hours. These departments have or will be adding residents, CRNAs, or faculty to fulfill these requirements (Table 3). Departments, on average, pay for four of their 39 residents and 58% (n = 51) of their CRNAs.
From a financial funds flow model, U.S. training departments can be divided into three types: "Academic Medical Center Model" (AMC Model) programs are those with departments within medical schools, "Budgeted Department Model" (Budgeted Model) are those in which departments are part of a larger clinical enterprise which manages the finances, and the "Independent Department Model" (Independent Model) wherein departments are structured like a private practice group (2). Because of the funding mechanism for Budgeted Model departments, they are unable to provide the financial data requested in these surveys and are therefore not included in the financial portion of the results (2).
For the fiscal year ending June 30, 2003, of the 78 program directors who responded to this question, 58% (n = 45) of departments had a positive financial margin whereas 38% (n = 30) had a negative financial margin, with 4% breaking even. For those departments with a positive margin, the mean margin was $636,338 or $15,908 per faculty full-time equivalent (FTE) (Table 4, Fig. 1a). Those departments with a negative margin had an average loss of $1,704,139 or $42,603 per faculty FTE (Table 4, Fig. 1a). When these data are compared with the last 3 years, they demonstrate that the percent of departments with positive and negative margins are similar, but that the positive margins are decreasing and the negative margins are increasing (Table 4, Fig. 1a).
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Figure 1. a. This figure illustrates the trends in financial margins of the departments (not including the Budgeted Model departments) over the 4 yr, 2000–2003. The margins are normalized to the number of faculty in each department. The percentage reported within the bars are the percentage of the departments with positive and negative margins respectively (1). b. These are the average department’s institutional support dollars for the years 2000, 2002, and 2003. *These data were not surveyed in 2001.
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The average institutional support totaled $3,424,296 or $85,607 per faculty FTE (Table 5, Fig. 1b). Fifty-nine percent of this support was received from the hospital whereas 18% and 23% were received from the medical school or other sources, respectively. When these data are compared with the previous survey results it appears that total institutional support per FTE has increased by 75% between the years 2000 and 2002 and then by another 43% in 2003.
The second survey in 2003 noted that 25% of departments had closed anesthetizing locations as a result of a lack of faculty and 14% had done so as a result of a lack of CRNAs. The average anesthesia unit charge was $74.80 (n = 75) (Table 5).
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Discussion
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During the late 1980s and early 1990s, anesthesiology in the U.S. was a very popular choice for U.S. medical students and the training programs progressively increased the size of their classes (7). The American Society of Anesthesiologists became concerned that the numbers of graduating residents would be larger than the national need and consequently commissioned a manpower analysis to be done by Abt Associates, Inc (10). This analysis reported in 1994 that although there may have been a considerable oversupply of anesthesiologists, this prediction depended upon a variety of assumptions, including growth rate of surgical procedures and the degree to which anesthesia was provided in the care team mode with supervision of CRNAs (10). Also in the mid-1990s, recommendations were being made that U.S. medical schools should be producing 50% specialists and 50% primary care providers. This recommendation was based on the expected need for primary care gatekeepers for the managed care and capitated programs of the future. In addition, a reduction in specialists would be appropriate given the anticipated reduction in subspecialty care and surgical procedures. On March 17, 1995, an article appeared in the Wall Street Journal that received significant attention in the medical school community. This article recounted the difficulties that a recent anesthesiology graduate had in finding employment (11). All of these forces directed medical students away from selecting a career in anesthesiology. The result was a dramatic decrease in the number of U.S. medical graduates entering into the match for anesthesiology in 1996.
It now appears that there is a substantial shortage of anesthesiologists that may persist for the next 5 to 10 years (3,4). Future needs in the U.S. anesthesia workforce have been proven to be very difficult to predict (3). United States workforce needs depend not only on estimated surgical caseload and practitioner retirement rate (which in turn may be dependent on the state of the economy) but also on the average work hours per practitioner and the percentage of anesthesiologists who will be working out of the operating room (OR), e.g., pain and critical care (3).
It is well documented that the salaries of faculty anesthesiologists who work in training programs are less than those of their private practice counterparts (2003 SAAC salary survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, 2003) (5,6). Anesthesiologists who choose academic careers have the opportunity to teach and participate in academic pursuits and consequently have an expectation to have academic time to participate in these nonclinical activities. When the number of faculty in a training department decreases, the department chair must either limit academic time or reduce coverage for the OR. Because most hospitals rely heavily on OR revenue, it is extremely difficult for an anesthesiology department to close ORs for the purposes of maintaining academic time for its faculty. From the results of this survey it appears that departments have both closed anesthetizing locations and reduced academic time. The survey demonstrates that 25% of departments have closed an anesthetizing location as a result of a lack of faculty.
In the 2000 survey, the average academic time was 20%, which has been reduced to 13.8% in 2003. As academic time is reduced, the job of a faculty in a training department becomes more similar to that of a private practitioner except for a smaller salary. For this reason, faculty may ultimately be recruited to better paying positions in private practice unless academic time is provided or salaries are maintained at a more competitive level. As the number of faculty openings in academic departments has been relatively constant over the past 4 years and the institutional support and academic salaries have increased significantly, it is clear that the training hospitals have realized the difficulty in recruiting and retaining the faculty without augmenting salaries (Table 5; 2003 SAAC salary survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, 2003). This does not address the problem of insufficient faculty and inadequate academic time, but it appears to have stabilized the faculty shortage in the academic departments.
It has also been noted that in recent years the percent of articles submitted to Anesthesiology and Anesthesia & Analgesia from U.S. departments has decreased compared with international departments (personal communications with Ronald Miller, MD, editor, Anesthesia & Analgesia and Michael Todd, MD, editor, Anesthesiology). Although this decrease in submission rate to the two primary U.S. anesthesiology journals does not in itself prove that academic productivity in U.S. departments is decreasing, it is a concerning trend. Additionally, should the number of anesthesiologists increase relative to demand, the hospitals would most likely reduce the current level of support, causing an acute decrease in salaries. Because over the short term increasing salaries cannot increase the number of anesthesiologists but only add to the workforce by reducing the number of retirees and increasing the number of hours worked per practitioner, the supply and demand effect on salaries may continue.
Survey data, in general, may misrepresent reality because of a small response rate, a skewed response population, or errors in the respondents understanding of the survey questions. The 65% response rate of this current survey compares favorably with the 25%–31% response rate of the Medical Group Management Association reports (5,6). In addition, because this is the fourth consecutive year of surveying the same population regarding a similar topic, it is likely that these data are at least consistent and potentially improved over the previous 3 years. The large response rate achieved in this survey is likely attributable to the fact that the respondent program directors were informed that they would receive the results of this survey at their national meeting and these results may be useful to them in managing their departments. This survey also compares well with the results of the most recent SAAC Salary Survey, which noted the average department had 39.5 faculty, whereas this current survey noted 40.3 faculty (personal communication with Rebecca Lovely, University of Florida, Gainesville, 2003). This same SAAC survey noted 266 funded faculty vacancy positions in the 86 responding departments. The current survey notes 69 of the 88 responding departments had an average of 3.7 faculty openings or 255 open faculty positions. This excellent agreement between these two surveys provides some evidence of accuracy or at least consistency.
It is possible that, although the response rate has been relatively consistent, the demographics of the respondents over time could have shifted and thus influenced the year-to-year comparison of mean values. Figure 2 presents the number of responding departments by faculty size over the 4-year period. There is no statistically significant change in distribution of responding departments by faculty size. Figure 3 presents the number of respondents by department funding category, i.e., AMC, Budgeted, and Independent Models. Although there were a significantly decreased number of Budgeted Model respondents after the year 2000, none of these departments are included in the financial analysis because of a lack of financial data for that group (2). The Independent Model and AMC Model responding departments have remained relatively constant over the 4 years (Fig. 3).
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Figure 2. This figure illustrates the number of responding departments in 4 groups by faculty size (0–20, 21–40, 41–60, more than 60) over 4 yr.  2 analysis revealed no differences in the distribution of responding programs between the 2000 and 2003 surveys.
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Figure 3. This figure illustrates the number of responding departments by department funding category (Academic Medical Center Model [AMC], Budgeted Model, and Independent Model). Although there appears to be a decrease in responding departments in the Budgeted Model, these departments did not contribute financial data.
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The institutional support per faculty FTE presented in Table 5 demonstrates a large variation between departments. One explanation for this wide range may be the expenses of CRNA salaries. The CRNAs may be employed by the hospital in some institutions and the expenses will not be part of the department expenses. In other departments the CRNA expenses are part of the department budget and these salary expenses may require significant support from the hospital. The 2000 survey found that 44% (n = 30) of the departments fully funded their CRNA salaries with 22% (n = 15) only partially funded their CRNA salaries. Thirty-four percent (n = 23) of CRNAs were completely funded by the hospital. The details of CRNA support dollars were beyond the scope of the three follow-up surveys, so the reason for the wide variation in hospital support cannot be definitively linked to CRNA costs.
We conclude that the current shortage of anesthesiologists in the U.S. has resulted in significant salary increases for faculty in the U.S. training programs and thus, departments have become increasingly dependent on institutional support to provide those salaries. Despite this increased funding, the financial condition of the U.S. departments is deteriorating, academic time is decreasing, and 25% of departments have closed an anesthetizing location because of a lack of faculty. These trends may gradually reverse as the size of the graduating residency class increases over the next 5 years.
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Appendix 1
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Appendix 2
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References
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- Tremper KK, Barker SJ, Gelman S, et al. A demographic, service, and financial survey of anesthesia training programs in the United States. Anesth Analg 2003; 96: 1432–46.[Abstract/Free Full Text]
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- Medical Group Management Association academic practice compensation and production survey for faculty and management: 2003 report based on 2002 data. Englewood, CO: MGMA Center for Research, 2003.
- Medical Group Management Association physician compensation and production survey: 2003 based on 2002 data. Englewood, CO: MGMA Center for Research, 2003.
- Tremper KK, Reves JG, Barker SJ, et al. The financial environment of academic anesthesia. In: Lake CL, Johnson JO, eds. Advances in Anesthesia. Carlsbad, CA: Mosby, Inc. 2001: 1–35.
- Tremper KK, Barker SJ, Gelman S, et al. Surviving the perfect storm: the financial environment of academic anesthesia, October 2000. White Paper Commissioned by Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors (SAAC/AAPD). Available at: http://www.asahq.org/aapd-saac/homepage.html.
- Accreditation Council for Graduate Medical Education, resident duty hour documents. Available at: http://www.ACGME.org.
- Estimation of physician workforce requirements in anesthesiology. Bethesda, MD: Abt Associates, Inc., 1994.
- Anders G. Once a hot specialty, anesthesiology cools as insurers scale back. Wall Street Journal. March 17, 1995.
Accepted for publication May 25, 2004.
This article has been cited by other articles:
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Top
Abstract
Introduction
