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You may not see it now, but anesthesiologists may soon be a precious commodity, in shorter supply than ever before. If current trends continue, there may be a shortage of up to 4,500 anesthesiologists by 2005, according to a recent Cleveland Clinic study. The impact on your facility could be devastating - forcing you to constantly scramble for anesthesia coverage or even to cancel cases. Outpatient Surgery spoke with the experts to get their advice on steps you can take today to prevent a possible anesthesiologist shortage from becoming a problem tomorrow.
1. Be flexible with work schedules.
The most commonly voiced concern among anesthesiologists, whether they have their own practice or are part of an anesthesia group, is the working environment of facilities, namely hospitals. "In a free marketplace, shortages exist where undesirability is perceived," says Barry Friedberg, MD, a volunteer instructor in clinical anesthesia at University of Southern California.
Although money is always a consideration, the best way to attract and keep good anesthesia providers is to be responsive to their needs. "Many people will take less money if there is a friendly, supportive environment," says Alan Marco, MD, MMM, associate professor of anesthesiology at the Medical College of Ohio in Toledo.
Work schedule is an issue of paramount concern to anesthesia providers. Says Dr. Marco, "Hours worked and OR schedules are important to everyone, but especially for PHOs, employed physicians and large group anesthesiologists." People's needs differ, so be as flexible with the provider who wants more call as you are with the provider who wants a 7-to-4 job, says Dr. Marco.
A little time off doesn't hurt either to spend time with family. Another idea: close an OR during the ASA meeting week or between Christmas and New Year's Day. Whatever you lose in cases scheduled for those times, you'll more than make up for in loyalty and lower turnover. "It's cheaper to retain customers or employees," says Dr. Marco, "than it is to recruit new ones."
Ambulatory surgery centers and office practices can use flexible hours to lure anesthesiologists away from hospitals. Office-based anesthesia is the specialty's fastest-growing segment of practice opportunity. Why? "Along with financial incentives, one of the major lures is that there is no night or weekend call. There is intense competition with CRNAs for this type of practice," says Dr. Friedberg.
2. Retool your anesthesia budget.
For an anesthesiologist coming out of medical school $100,000 in debt, salary is going to be a huge consideration in any job that he accepts. Says Dr. Marco, "In this era of declining reimbursements, it's tough for facilities to offer salaries that will instantly make an anesthesiologist jump at the job."
Nevertheless, facilities are finding it necessary to increase financial incentives for anesthesiologists. "Anesthesiologist salaries are increasing across the board," says John Abenstein, MD, of the Mayo Clinic in Rochester, Minn. "There's no other alternative, because administrators are desperate for the providers." Additionally, a growing number of anesthesia groups are being offered partnerships in surgical facilities.
Your facility can fairly compensate the anesthesiologist for his services while still minding the bottom line. You can do this by supporting the anesthesiologist with staff that can take over technical and clerical support. Says Dr. Marco, "In a previous practice, I had to turn over the OR at night, including cleaning the anesthesia machine and equipment. I didn't mind doing the work, but it made no sense from a facility standpoint. Why pay me to do it instead of a tech at a much lower rate?"
3. Consider non-physician providers.
The debate over the qualifications of CRNAs to provide unsupervised anesthesia care continues to rage. Regardless, independent CRNAs are a fact of life in many surgery centers. Says Dr. Marco, "I do not support the idea of CRNAs practicing independently. I believe that all anesthetics should be administered by an anesthesiologist or by a nurse medically directed by an anesthesiologist. However, I recognize that this is probably not possible with the current situation. Using non-physician providers may be a solution in some settings."
Unfortunately, the ranks of nurse anesthetists are also falling victim to shortages. There are about 25,000 active CRNAs practicing in the United States, but the numbers are going down. "We're part of the nursing shortage as well as the anesthesia shortage," says Larry Hornsby, past president of the American Association of Nurse Anesthetists (AANA).
The best strategy for dealing with the dual shortage? Create anesthesia care teams, which use fewer anesthesiologists and fill out the team with nurse anesthetists. "This is how many hospitals are keeping ORs open," says Lee Hammerling, MD, the CMO of Promedica Health System in Ohio and himself an anesthesiologist.
Another option: further supplement the team with AAs (Anesthesia Assistants), says anesthesiologist John Neeld, MD, of North Side Anesthesia Services. Fourteen states recognize the AA degree, which involves master's level education, two years of hands-on didactic basic science, technical training on anesthesia equipment and 30 months of clinical training. Conversely, a CRNA receives four years of nursing school, at least one year of critical care experience and a 24- to 36-month graduate degree program in anesthesia. AAs are not licensed to practice without anesthesiologist supervision, but they may be a viable option for filling out an anesthesia care team and providing some of the technical and clerical support that will let your more experienced providers have more time to devote to the OR.
4. Schedule fewer cases or limit OR access.
Implement this far-from-ideal strategy only when other methods fail for keeping the ORs going at full capacity. "Tightening the belt is never pleasant," notes Dr. Hammerling, "but your OR schedule also has to reflect the availability of anesthesia care. Especially in the hospital setting, it is something that has to be considered."
As Jefferson City, Mo., consultant Dawn Cavanaugh notes, cutting back on scheduling cases only works for high-volume and non-profit centers. If you are a two-OR ambulatory surgery center and you're limiting hours or closing off an OR due to lack of anesthesia coverage, "you simply didn't do your homework beforehand about the anesthesia provider availability in your area."
5. Go back to school.
While the emphasis is on recruiting and retaining experienced providers, don't neglect the future. Many anesthesia programs have noted recent increases in enrollment. Increasingly, the schools are trying to reach out to facilities to help them give their students exposure to the clinical setting. Why not support post-graduate placement programs and let prospective students visit your facility? Your facility will be doing a service to the students and, in the long run, yourselves.
"What are the benefits of grabbing these men and women early?" asks Dr. Hammerling. "In the first place, you can show them what life is actually like in your facility. You are giving them a practical education to supplement their clinical education. Secondly, you are establishing a potentially valuable contact with the medical school, which can help channel some of their top anesthesia graduates your way. It's a bit of early recruiting that is not all that different from what smart companies do with young MBA students."
Similar opportunities exist with bringing CRNA students to your facility. One ray of hope in the CRNA shortage, according to Mr. Hornsby, is the recent passage of the Nurse Reinvestment Act, which will let nursing students work in clinical settings while furthering their education. Mr. Hornsby believes that this will benefit the cause of bringing more CRNAs into the OR, although it will not solve the problem in and of itself.
Use common sense and creativity
Although the anesthesia provider picture is not rosy, there are ways to shield your facility from harm. A combination of common sense and a little creativity will ensure that your facility will be able to accept cases without fear of scheduling headaches or cancellation due to lack of anesthesia coverage.
1. Be flexible with work schedules.
The most commonly voiced concern among anesthesiologists, whether they have their own practice or are part of an anesthesia group, is the working environment of facilities, namely hospitals. "In a free marketplace, shortages exist where undesirability is perceived," says Barry Friedberg, MD, a volunteer instructor in clinical anesthesia at University of Southern California.Although money is always a consideration, the best way to attract and keep good anesthesia providers is to be responsive to their needs. "Many people will take less money if there is a friendly, supportive environment," says Alan Marco, MD, MMM, associate professor of anesthesiology at the Medical College of Ohio in Toledo.
Work schedule is an issue of paramount concern to anesthesia providers. Says Dr. Marco, "Hours worked and OR schedules are important to everyone, but especially for PHOs, employed physicians and large group anesthesiologists." People's needs differ, so be as flexible with the provider who wants more call as you are with the provider who wants a 7-to-4 job, says Dr. Marco.
A little time off doesn't hurt either to spend time with family. Another idea: close an OR during the ASA meeting week or between Christmas and New Year's Day. Whatever you lose in cases scheduled for those times, you'll more than make up for in loyalty and lower turnover. "It's cheaper to retain customers or employees," says Dr. Marco, "than it is to recruit new ones."
Ambulatory surgery centers and office practices can use flexible hours to lure anesthesiologists away from hospitals. Office-based anesthesia is the specialty's fastest-growing segment of practice opportunity. Why? "Along with financial incentives, one of the major lures is that there is no night or weekend call. There is intense competition with CRNAs for this type of practice," says Dr. Friedberg.
2. Retool your anesthesia budget.
For an anesthesiologist coming out of medical school $100,000 in debt, salary is going to be a huge consideration in any job that he accepts. Says Dr. Marco, "In this era of declining reimbursements, it's tough for facilities to offer salaries that will instantly make an anesthesiologist jump at the job."
Nevertheless, facilities are finding it necessary to increase financial incentives for anesthesiologists. "Anesthesiologist salaries are increasing across the board," says John Abenstein, MD, of the Mayo Clinic in Rochester, Minn. "There's no other alternative, because administrators are desperate for the providers." Additionally, a growing number of anesthesia groups are being offered partnerships in surgical facilities.
Your facility can fairly compensate the anesthesiologist for his services while still minding the bottom line. You can do this by supporting the anesthesiologist with staff that can take over technical and clerical support. Says Dr. Marco, "In a previous practice, I had to turn over the OR at night, including cleaning the anesthesia machine and equipment. I didn't mind doing the work, but it made no sense from a facility standpoint. Why pay me to do it instead of a tech at a much lower rate?"
3. Consider non-physician providers.
The debate over the qualifications of CRNAs to provide unsupervised anesthesia care continues to rage. Regardless, independent CRNAs are a fact of life in many surgery centers. Says Dr. Marco, "I do not support the idea of CRNAs practicing independently. I believe that all anesthetics should be administered by an anesthesiologist or by a nurse medically directed by an anesthesiologist. However, I recognize that this is probably not possible with the current situation. Using non-physician providers may be a solution in some settings."
Unfortunately, the ranks of nurse anesthetists are also falling victim to shortages. There are about 25,000 active CRNAs practicing in the United States, but the numbers are going down. "We're part of the nursing shortage as well as the anesthesia shortage," says Larry Hornsby, past president of the American Association of Nurse Anesthetists (AANA).
The best strategy for dealing with the dual shortage? Create anesthesia care teams, which use fewer anesthesiologists and fill out the team with nurse anesthetists. "This is how many hospitals are keeping ORs open," says Lee Hammerling, MD, the CMO of Promedica Health System in Ohio and himself an anesthesiologist.
Another option: further supplement the team with AAs (Anesthesia Assistants), says anesthesiologist John Neeld, MD, of North Side Anesthesia Services. Fourteen states recognize the AA degree, which involves master's level education, two years of hands-on didactic basic science, technical training on anesthesia equipment and 30 months of clinical training. Conversely, a CRNA receives four years of nursing school, at least one year of critical care experience and a 24- to 36-month graduate degree program in anesthesia. AAs are not licensed to practice without anesthesiologist supervision, but they may be a viable option for filling out an anesthesia care team and providing some of the technical and clerical support that will let your more experienced providers have more time to devote to the OR.
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4. Schedule fewer cases or limit OR access.
Implement this far-from-ideal strategy only when other methods fail for keeping the ORs going at full capacity. "Tightening the belt is never pleasant," notes Dr. Hammerling, "but your OR schedule also has to reflect the availability of anesthesia care. Especially in the hospital setting, it is something that has to be considered."
As Jefferson City, Mo., consultant Dawn Cavanaugh notes, cutting back on scheduling cases only works for high-volume and non-profit centers. If you are a two-OR ambulatory surgery center and you're limiting hours or closing off an OR due to lack of anesthesia coverage, "you simply didn't do your homework beforehand about the anesthesia provider availability in your area."
5. Go back to school.
While the emphasis is on recruiting and retaining experienced providers, don't neglect the future. Many anesthesia programs have noted recent increases in enrollment. Increasingly, the schools are trying to reach out to facilities to help them give their students exposure to the clinical setting. Why not support post-graduate placement programs and let prospective students visit your facility? Your facility will be doing a service to the students and, in the long run, yourselves.
"What are the benefits of grabbing these men and women early?" asks Dr. Hammerling. "In the first place, you can show them what life is actually like in your facility. You are giving them a practical education to supplement their clinical education. Secondly, you are establishing a potentially valuable contact with the medical school, which can help channel some of their top anesthesia graduates your way. It's a bit of early recruiting that is not all that different from what smart companies do with young MBA students."
Similar opportunities exist with bringing CRNA students to your facility. One ray of hope in the CRNA shortage, according to Mr. Hornsby, is the recent passage of the Nurse Reinvestment Act, which will let nursing students work in clinical settings while furthering their education. Mr. Hornsby believes that this will benefit the cause of bringing more CRNAs into the OR, although it will not solve the problem in and of itself.
Use common sense and creativity
Although the anesthesia provider picture is not rosy, there are ways to shield your facility from harm. A combination of common sense and a little creativity will ensure that your facility will be able to accept cases without fear of scheduling headaches or cancellation due to lack of anesthesia coverage.
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