Reader response

Myron Yaster MD

From David Salama MD

As the head of a small private practice anesthesia group I found the two part series on the anesthesia workforce to be informative and timely.  Here are some of my thoughts…

The recent analysis of the anesthesia workforce supply and demand imbalance offers valuable insights but too quickly glanced over an important factor: the proliferation of Ambulatory Surgery Centers (ASCs) over the past 30 years. ASCs and endoscopy centers have drastically shifted where surgical and anesthesia services are provided, with surgeons often collecting both facility fees and, in some cases, anesthesia revenue paying out lucrative per diem rates to anesthesiologists and CRNAS. This model incentivizes anesthesiologists to leave hospital settings for ASCs, which offer more attractive schedules with no holidays, weekends, or nights.

This migration significantly impacts hospitals, which are essential all our communities for providing complex care such as trauma, cancer surgeries, pediatric heart surgeries, transplant services etc…  The exodus of anesthesiologists to ASCs leaves hospitals understaffed, compromising the quality and availability of care for patients with the most critical needs. 

While ASCs serve an important role, their growth has disrupted the balance, leaving hospitals with more complex and less financially lucrative cases. Addressing this issue requires realigning incentives to ensure hospitals can retain skilled anesthesia providers. This includes revisiting financial models and fostering a more balanced distribution of surgical cases between ASCs and hospitals. Though I fear it’s likely too late. Recognizing and addressing this imbalance is crucial to maintaining a functional healthcare system that provides high-quality care for all patients.

Another important point is the increasing number of women entering medicine over the last 30 years, with medical school enrollments now over 50% female. Although anesthesia is not yet at a 50/50 gender balance, it has seen substantial growth in female representation. Many residents delay having children until after graduation due to the pressures of residency, which still operates under an archaic mindset when it comes to being supportive of having children while in training. Other western countries are seemingly more supportive of those starting families while in training. Residents today often complete their training in their early to mid-30s, partly because gaining entry to medical school now frequently requires additional years of education, research, or experience then it used to just 20-30 years ago. 

Given these circumstances, it should not be surprising that many residents seek jobs with a good work-life balance and decent salaries to pay off record levels of medical school debt when they finish their training. This desire further complicates the anesthesia workforce supply-demand issue. Understanding and addressing the unique needs of this evolving workforce is essential for creating a sustainable and supportive environment for all anesthesia professionals.

From Jeffrey M. Feldman, MD, MSE, FASA, Adjunct Professor of Clinical Anesthesiology, Children's Hospital of Philadelphia

Interesting discussion in the two part article.  Here is a comment for your consideration for the PAAD.  Hope it is not too long.

When I was first introduced to Anesthesiology as a specialty, I remember thinking to myself "I want to be a part of that."  I was drawn to the OR and ICU environments.  The opportunity to learn concepts of physiology and pharmacology and apply that knowledge to care for complex patients was compelling.  Just as compelling was the opportunity to become a member of a perioperative team and enjoy the collegiality of like-minded colleagues as we pursued meaningful work.  Over the years there were certainly times when I worked harder and longer than I might have preferred. but for the most part, the job aligned with my personal values and was central to my work/life balance.

In more recent years, it seems that job satisfaction in our field, and medicine in general, has become harder to find.  The knowledge and skills required to do the job well have only become more interesting but that does not seem to be sufficient to drive satisfaction.  In my view, what has changed notably is an erosion of the collegial relationships in the work environment.  There are many potential factors - the dramatic expansion of the number of people involved with perioperative services as departments and health systems have grown, the notion that work/life balance is not a synergy of activities that all align with personal values but a separation of the two and the increasing reliance on temporary workers who come and go without an opportunity to develop enduring relationships.  Of course, the pandemic turbocharged the social isolation, but I don't believe it is the core problem.  In my own experience over the last few years, I have had a schedule where I rarely worked with the same people on any regular basis, and it was completely unpredictable when I met encounter a colleague I enjoyed working with.  

I applaud the current generation of leaders who are committed to the future of our specialty.   The path forward to address the workforce challenge is not the path we have walked in the past.  As you think about strategies to address the challenges, emphasizing and restoring opportunities for meaningful collegial relationships will be important.  Perhaps there needs to be an approach to scheduling where people have an opportunity to work together in a concentrated manner for days or weeks before moving on to the next team.  Perhaps the morning time-out could include a recognition of a birthday or other happy life event.  The metric of success for every department will be the people who interview, or students who rotate, and walk away saying "I want to be a part of that."