Reader response

Myron Yaster MD

From Brett Murphy DO Assistant Professor of Anesthesiology, Baystate Medical Center

I'm responding to the article about the decrease in pediatric anesthesia fellowship applicants. To me, the decrease is pretty much all financially related. I have run the recruiting for our group for the last five years and have kept close tabs on the market. Pre pandemic most academic anesthesiologists were making somewhere between $300,000-400,000. This may be a little low in some areas like the Southeast but that's what it was in New England. In the last five years starting salaries have increased by as much as 50%. As a new grad you can easily find jobs paying $550-600,000. Meanwhile the salaries for residents and fellows has remained stagnant. A pediatric anesthesia fellow can expect to make between $75-100,000 a year. If you assume a pedi fellow salary of $90,000 at an effective tax rate of 25% and an attending salary of $550,000 at an effective tax rate of 33% it is a difference of $302,000 in take home pay! If one takes the advice of Dr. Jim Dahle (the White Coat Investor) and "live like a resident" for just one year to invest that $302,000 the effects are astounding. Throw that number in a compound interest calculator at just 6% and assume a 25 year career. That $302,000 over 25 years becomes $1,296,000! It is a literal million dollar decision to do a fellowship. The real question is at this pay differential why would someone choose a fellowship? The solution is Econ 101: if nobody is applying your job then you aren't paying enough. These programs are getting an attending anesthesiologist in a competitive environment and need to pay them more.

As the author mentioned pre-pandemic there was a glut of pedi anesthesia applicants and eventually pedi anesthesiologists. Did these programs then decrease the number of fellows in order to maintain a healthy job market for years to come? No, they continued to expand. There were even significant rumors of lengthening the pedi fellowship to 2 years. These programs did these things to obtain and maintain cheap labor. Now these same programs are complaining they can't fill but won't make basic economic adjustments. On a related note Emergency Medicine (in my previous life I was an ER attending) has announced they will be moving to a 4 year program model from a 3 year program model. They cite survey results from program directors, decreasing test scores and a glut of staff. Yet in the past ten years ER residency spots have ballooned from around 1500 to around 2500! A huge portion of this is due to the explosion of privately funded ER residencies by for profit entities. Were these counterpoints mentioned in the argument to expand? I think we can all agree that with a dramatic expansion of for profit residencies the education may not be prioritized. Other medical fields are no better. The AAP mandates that all fellowships be three years. Surgeons regularly do 1-2 years of research in addition to a five year residency and a 1-2 year fellowship. This all happens in the face of a critical physician shortage in the United States. We should be researching how to shorten training, not lengthen it. These critical shortages are a primary driver of mid-level encroachment. CRNA's, NP's and PA's are taking the place of physicians out of necessity. When are we going to stop punishing our own? When are academic institutions going to start taking these factors into account? I'm tired of seeing programs take advantage of hard working resident physicians that are drowning in debt. Until these questions start being asked more frequently we will not find any real solutions.

From Amr Abouleish, MD, MBA, Vice Chair of Faculty Development, Compliance Officer University of Texas Medical Branch at Galveston, Professor, Anesthesiology In response to PAAD: Addressing late-arriving surgeons in support of first case on time starts

Any anesthesiologist with at least five years of experience will inevitably encounter a project aimed at either improving first-case on-time starts or reducing turnover time. The paper discussed in the PAAD, along with the two referenced studies, each highlight a quality improvement (QI) project from a different institution addressing this issue. These studies serve as strong examples of successful behavior modification programs.

I agree that professionalism and improved morale are valuable outcomes of such initiatives. In pediatric anesthesia, knowing the precise start time of the first case simplifies the timing of premedications. However, none of these projects examine broader operational metrics such as turnover efficiency, overall OR throughput, end-of-day finishing times, or staff “stay time” beyond regular shifts.

I disagree with the notion that saving minutes at the start of the day translates directly into financial savings without considering the impact on the end of the day. For instance, if a surgeon scheduled for 7:15 AM consistently arrives at 7:45 AM but still finishes by 2:00 PM—before the OR staff’s shift ends at 3:00 PM—and no additional cases are scheduled in that room, then enforcing an earlier arrival does not yield financial benefits. Moreover, the reports do not specify turnover times or address the possibility of prolonged intervals, even when first-case start times improve.

The reason projects focused on “first case start” and “turnover time” are so common is that these metrics are straightforward to track and report. However, tracking delays once a patient is in the OR is far more complex. Neither initiative alone guarantees improved OR throughput. Nevertheless, I strongly recommend that anesthesiologists take the lead on these projects—otherwise, anesthesia is likely to be blamed when issues arise.

If you want to improve OR throughput, you need to look at the whole perioperative experience. See Table 1 from J am Coll Surg 2011;213:83-94 (PMID 21420879, 10.1016/j.jamcollsurg.2011.02.009)

If you are hoping for improved OR throughput by focusing on first case starts, you should read the classic management paper entitled “On the folly of rewarding A, while hoping for B”! (https://web.mit.edu/curhan/www/docs/Articles/15341_Readings/Motivation/Kerr_Folly_of_rewarding_A_while_hoping_for_B.pdf)

From Andrew Matisoff, MD, The Hospital for Sick Children

Thank you for the insightful article on current staffing challenges in pediatric cardiac anesthesia. One dramatic change that I have noticed in the last 10 years has been an increase in surgical complexity across all programs. We are operating on higher risk, smaller and younger patients, many with genetic syndromes. In addition we are more likely to bring children back for multiple operations or have multiple bypass runs to achieve better technical results. The end result of this is much longer days in the operating room, more instability post bypass including bleeding, and more tired staff. These long days are experienced by fellows too, so it is not surprising that they are not pursuing additional training in peds cardiac anesthesia. A key role in addressing the staffing shortage is recognition from both the hospital and departmental administration the challenging and demanding nature of the field, and the impact these long days have on the staff. We should not expect these same staff to complete general cases after finishing a cardiac case or to cover the complex neonate in the general surgery OR on their non cardiac day when admin time is threatened by staffing shortages. Additionally coverage of low risk catheterization procedures and electrophysiology cases by non cardiac staff is not unreasonable.