Using anesthesiology as a model for change.

ANESTHESIOLOGISTS, AS MEDICAL SPECIALISTS, continue to make front page headlines in The Wall Street Journal and American Medical News. (1,2) Nothing seems to sell like bad news. Today, anesthesiology is being shunned by American medical graduates as an oversupplied specialty. Moreover, perceptions by medical students, anesthesiology residents, and medical school deans foster the conclusion that job opportunities have evaporated.

In only a decade, anesthesiology has reversed its fortunes from an underrepresented specialty in the Graduate Medical Education National Advisory Committee (GMENAC) report of 1980 to "a specialty in trouble" featured in The Wall Street Journal. (1,3) What happened? More to the point, what are anesthesiology practitioners across the U.S. going to do to reinvent this specialty for the realities of a radically changing health care environment?

Can anesthesiology serve as a model for the change process? What is happening to anesthesiology will not be unique--managed care competition will radically affect all physicians. What are the options for simultaneously coping with physicians grieving over lost dreams, such as autonomy and solo practice, while redesigning a medical specialty? Presented here, some ideas on how to untangle fact from fear, mission from myth, and using strategic thinking and new solutions as therapy for the numbing paralysis of future shock. (4)

Academic medical centers

With the new rules of managed care, academic medical centers (AMCs) are caught in a reversal of mission just for survival. The traditional goals of teaching and research, with a minimum clinical base, have been turned upside down. The once unchallenged academic twosome is being overwhelmed by the financial need to increase clinical services. AMCs are compelled to substitute patient care practice dollars for eroding teaching and research funds. A study of seven AMCs published last summer in Health Affairs, for example, found that AMCs charged 15 to 35 percent more for each inpatient admission than the community hospitals, their competitors. (5)

Facing an increasingly price-sensitive managed care market, potential loss of direct and indirect support from Medicare and Medicaid programs, and a dwindling patient referral base, AMCs are scrambling. They are reducing costs, adapting and downsizing residency training programs, and expanding clinical services to capture a larger network of "covered lives."

Will scientific research advances, as well as teaching future generations of providers, be left in the dust of the stampede toward price-sensitive managed care and cost containment? This fundamental question for policymakers must be addressed. Meanwhile, anesthesiology training programs, as well as community practitioners, find themselves thrust into a historically defining moment of epic proportions.

Defining moments

In 1996, anesthesia celebrated its 150th birthday. It's first defining moment was the truly American discovery of anesthesia on October 16, 1846, with the demonstration of ether administration at the Massachusetts General Hospital, in Boston. Each year, Doctors' Day, on March 30th, commemorates this achievement. This discovery eliminated pain and human suffering from surgical operations; (6) it led to what some observers called a spiritual revolution as well, by ending the belief that suffering pain was humankind's God-decreed fate in life. Moreover, anesthesia changed surgery itself and views of pain.

The second marked change occurred when anesthesia moved from a technical skill, often called "dripping ether," to become a legitimate medical specialty following World War II. Biomedical and clinical research emphasized the sciences of pharmacology and physiology, as well as applying anesthesiology research findings to reduce deaths. This investigative underpinning formed a new medical specialty in 1938. The American Board of Anesthesiology, through written and oral examinations, began granting official recognition of physicians competent to practice and teach anesthesiology. In addition, visionary anesthesiologists established departments in major U.S. medical schools, often as an outgrowth of academic departments of surgery.

Today, anesthesiology is experiencing its third defining moment. A work force crisis in both academic and community practices has resulted from the impact of market-driven health care reform and unbridled American free-market competition. The specialty must reinvent itself to remain a unique value in the altered marketplace.

Over the last three years, the concept of managed care has become the mantra for U.S. health care cost containment. Free-market economic forces have been unleashed to accelerate changes based on the economic incentives of the corporate world. The socially amoral rules of competition prevail. Such competition recognizes only unemotional, win-lose rules, unencumbered by the 50-year-old culture of a traditional cottage industry, patient choice, or preferential community referral patterns developed by fee-for-service medicine.

When implementing exclusively the driving principle of cost containment, health care becomes just another commodity bought at the lowest price. What results? High technology, procedure-driven medicine shifts toward low technology health care. Hospital admissions, surgical procedures, and specialists become cost centers, not the previously highly-valued profit centers. Suddenly, a new emphasis on integrated services appears with the need for a strong primary care base. Specialists are out, generalists are in.

Cost containment

What are the consequences when cost containment becomes the preeminent engine of U.S. health care? Free-market competition drives down reimbursement for services, reduces utilization, and changes the supply/ demand equation for all personnel. For example, the need for specialists decreases, but especially the demand for hospital-based anesthesiologists, radiologists, and pathologists.

Anesthesiologists, as might be expected, have experienced, initially, the most precipitous curtailment in demand. However, as hospitals close, downsize, and "rightsize," positions are being eliminated for hospital administrators, nurses, pharmacists, and paramedical technical support personnel. (7) Moreover, in the drive to reduce costly inpatient hospitalization, explosive economic incentives accelerate the stampede to ambulatory care. Whereas 88 percent of all surgery was performed in a hospital prior to 1982, today more than 60 percent of operative procedures are performed outside the traditional hospital setting.

However, this reversal of inpatient care happens without either an appreciation for, or a proactive plan to address, the consequences. A new and essential comprehensive ambulatory infrastructure for patient support services does not exist in most communities. What results is a scramble by all health care personnel, as well as patients, to survive this tumult of confusion as the old familiar systems of delivery and financing change.

Health care workers must now give up their dreams of stable jobs. For the first time ever, falling physician incomes, a glut of specialists, nurses out of work, and daily job insecurity is invading the previously sustained growth of the industry. (8) This somnolent service giant is neither prepared nor equipped yet to manage free-market competition. If in doubt, just observe how we continue compiling patient records using a rudimentary pen and paper charting system! Moreover, what about the status of U.S. physician manpower presently and in the future?

U.S. physician work force

The shift from fee-for-service reimbursement to service-for-a-fee (capitation), coupled with the explosive growth of integrated delivery systems, profoundly affects the requirements for the physician work force. Mergers, acquisitions, alliances, and consolidations of medical practices, hospitals, and academic centers occur daily. Such competitive tactics gain economies of scale, reduce personnel costs, and focus on bulk buying and purchasing. What emerges is the public perception of a glut of hospital beds and physicians. This perceived oversupply of specialists is not unique to anesthesiology. But Rivo and Kindig state that from 1970 to the year 2000, the supply of practicing physicians will increase from 156 to 261 per 100,000 of the U.S. population. (9) Will the demand for physician services match these numbers? What does this change mean for health care? Is this good or bad for Americans?

Unlike any other industrialized country, the U.S. does not have a health care reimbursement and medical education financing strategy to address society's need for physicians. (10) Consequently, it should be no surprise that there is a problem with matching the annual supply of physicians with society's need for doctors. (11) Moreover, the trickle-down of physicians to rural and underserved communities has not occurred, despite a net increase of 125,000 physicians entering the work force over the last 10 years. (12) Physician distribution has become heterogeneous, not uniform or needs-based. The highest physician-to-population ratios do not reflect public need, but rather the number, location, and size of residency programs.

For example, the Boston-Washington corridor has 21 percent of the population, but 28 percent of the physicians (an average ratio of 270 per 100,000 population). Compared with the rest of the nation (on a per capita basis), it has 25 percent more practicing physicians and more than double the number of residents. (13) The largest concentration of anesthesia residency positions exists in the states of New York and Massachusetts, and this region has the highest number of practicing anesthesiologists per population. (10) At the other extreme lies Mississippi, with a ratio of 118 physicians-per-100,000-population, and the lowest number of physicians and non-physician clinicians in the nation. (13)

Managed care projections

What about the impact of managed care on physician supply? Weiner predicted that within four years, there will be a surplus of 165,000 physicians overall and an astonishing 60 percent oversupply of specialists. (14) These predictions assume that between 40 and 55 percent of Americans will be members of managed care networks. Northern California, for example, already has an estimated 90 percent managed care penetration; since 1991, this rapidly advancing shift has meant a 42 percent decline in hospital use, falling occupancy rates, declining specialists incomes, and a growing surplus of hospital beds and specialists. (15)

Such dramatic projections and examples have stimulated governmental, educational, and private foundation commissions, as well as task forces, to study and suggest strategies. Such broad-based study groups include the Council on Graduate Medical Education (COGME), which advises Congress on matters of Graduate Medical Education (GME), the Physician Payment Review Commission, which advises Congress on Medicare physician payments, the Association of American Medical Colleges (AAMC), the Institute of Medicine (IOM), and the Pew Health Professions Commission. Conclusions are remarkably consistent and sobering.

The Pew authors believe that 50 percent of hospitals and 60 percent of acute inpatient beds will be gone by the year 2000. (7) In addition, 200,000 to 300,000 registered nurses will be unemployed. Moreover, that commission recommends a reduction in overall residency positions to 110 percent of the number of American medical school graduates and a reduction of entering medical school class size by 20 to 25 percent by the year 2005. (7)

Enter anesthesiology

In the 1980s, anesthesiology became the fastest growing medical specialty. In only a 12-year period (1980-1992), the American Society of Anesthesiologists (ASA) grew to include 22,463 active physician members. (16) The predominant mode of practice (65-70 percent) today remains the anesthesia care team (ACT), where about 22,000 certified registered nurse anesthetists (CRNAs) practice with medical direction from roughly 22,000 anesthesiologists. (10)

Anesthesiology has been successful in moving from an undersupplied medical specialty before 1980 to one of abundant physician specialists for the anticipated high-technology, fee-for-service health care system. Unfortunately, something happened on the highway to high-technology medicine. The U.S. health care paradigm shifted to a low-technology, primary care emphasis to curtail costs.

Even so, this "physician boom" of anesthesiologists has enormously benefited American society through improved clinical outcomes and decreased patient risks for operations. Anesthesiology finds itself mired in a crisis of success. Perioperative mortality associated with anesthesia and operation has markedly decreased from 1:1,000 in 1942 to 1:250,000 today, despite more complex surgical procedures performed on sicker patients. (17)

Recently, Silber et al, analyzed factors that contribute to mortality (death rates), complications (adverse event rates), and failure to rescue (resuscitate) after operation. (18) Death rate and failure to rescue from complications were inversely related to the proportion of board certified anesthesiologists on the staff of each hospital studied. Said in a positive way for patient care, as the number of board certified anesthesiologists on each medical staff increased, death rates decreased.

These studies--by an internist and pediatrician--support the value of board certified anesthesiologists in delivering care. In order to study and measure anesthesia risks, the ASA established and funded in 1985 an international foundation to focus on improved safety. In October, 1996, the American Medical Association (AMA) patterned its new medical foundation for risk management after the ASA model. The AMA plans to focus on reducing untoward events associated with all clinical care, not just anesthesia and operations. (19)

Nevertheless, managed care continues to reduce the demand for all specialists. As hospitals have consolidated, the job market has tightened for anesthesia providers. The pendulum of supply and demand has over-corrected, due to the shear momentum of negative publicity. Adverse media coverage has been reinforced by some physician colleagues, especially those in academic medical centers. In 1992, Medical students began to deselect anesthesiology in the National Resident Matching Program (NRMP).

Despite anesthesiology residency programs offering fewer positions in the national match, the percent of slots filled--and more dramatically the percent filled by American medical graduates (AMGs)--has plummeted (see Figure 1). By March of 1996, a total of 169 AMGs matched in Anesthesiology at the postgraduate year one and two (PGY 1 & 2) levels. This cohort was joined by 155 International Medical Graduates (IMGs) in filling a total of 324 PGY 1 & 2 entry level positions out of 966 offered (33.8 percent filled). A new managed care number, not fee-for-service supply/demand equilibrium, is evolving for the specialty, driven by market forces, not regulations. How many anesthesiology graduates per year will meet the needs of the emerging managed care paradigm?

The Abt Report

In 1994, the ASA employed the Abt Associates of Boston to create scenarios that address the future supply of anesthesiologists until 2010. These data could begin to assist anesthesiology GME programs in proactive planning.

For example, if a mix of anesthesia providers were 25 percent physician only, 65 percent anesthesia care team (ACT), and 10 percent CRNA only (the case in 1993), and with anesthesiologists continuing their average 62-hour work weeks and retiring at age 65, programs would need to graduate 600 residents annually. (20) This provider mix assumes there is an anesthesiologist directing a CRNA, resident physician, or anesthesiologist assistant (PA) during the care of relatively healthy patients. Each physician works "hands on" with another provider in the operating room and is immediately available.

The benefits of this observational synergism by multiple providers are well-documented in the delivery of high risk, high intensity care. When a problem occurs with a patient, as in the intensive care unit, more than one physician and nurse are available to provide care. Changing the ratio to 1:2 to account for a more representative inpatient hospital patient intensity mix and keeping all other determinants for anesthesiologists constant (i.e., hours worked, mix of providers nationally, and retirement age) would increase the annual demand for graduating anesthesiologists to about 800-900.20 These two numbers fall below the 1,700-1,800 graduates from Anesthesiology programs in 1996.

The challenge for the specialty will be to retain quality programs for future anesthesiologists, while downsizing the output of graduates. Developing programs was fun and exciting--downsizing and retrenchment will bruise egos and cause discomfort. Some residency programs will close or consolidate, but most will reduce the number of graduating anesthesiologists substantially. Downsizing any organization is problematic, but especially in the culture of academic medical education that has evolved as a constantly growing enterprise. Rarely, if ever, has academic leadership considered reducing either educational or research programs.

Wishful thinking

Some colleagues in academic anesthesiology express the belief that the surplus will be followed in four years by a shortage. Such an assumption, although temporarily comforting, fails to acknowledge three facts. First, our "physician boom" has produced, in the last 12 to 15 years, a youthful medical specialty. Eighty percent of ASA members are 25-54 years of age. (16) In addition, the professional life expectancy of physicians averages 35 years. Such a demographic doubling of the anesthesiologist supply produces a cohort bulge of specialists. Each must be assimilated into the marketplace for long term practice.

Second, to produce a shortage of anesthesiologists in four years would require that positions be limited to those filled in the match (i.e., 323 in 1996). This simply has not happened. In the 15 months after each year's match, programs continue to recruit before the training period begins, particularly among IMGs and others not participating in the match. Why? The financial incentive for hospitals and the service advantage of cheap, often off-budget labor by programs remains seductive. Consequently, all unfilled match positions are not eliminated.

Finally, consider the unrelenting shift of the marketplace to the managed care paradigm. Those new rules reduce the need for specialists, control patient utilization of services (e.g. operations) and hospitalization by using "gatekeepers," and emphasize cost reductions by employing more non-physician clinicians. Anesthesiologists and surgeons are not spared when hospitals reengineer. Operative procedures are curtailed, delayed, or even eliminated. Anesthesiology--as principally a procedure-based, high-technology specialty--has absorbed the early brunt of reduced demand from managed care. New strategies, ideas, and innovative adjustments must be made in community and academic practice to meet the challenges facing the profession.

Job opportunities

As noted earlier, nothing travels faster than bad news, especially if it's fueled by biases. Articles with eye-catching, anecdotal examples of unemployed or underemployed recent anesthesiology graduates appeared--even The Wall Street Journal featured a front page story reinforcing these perceptions. (1) Beyond perceptions and rumor, are there any data on practice opportunities?

To answer this question, some historical perspective is necessary. The apparent certainty of the far-reaching Clinton Health Plan of 1993-94 created job insecurity for all practicing physicians. By January, 1994, recruiting new anesthesiologists almost ceased. Like deer frozen in headlights, most medical groups canceled practice expansion plans. What resulted for 1,800 new anesthesiology graduates (1993-94 academic year) was an instant restriction in the marketplace with limited choices. Moreover, the pervasive "doom and gloom" attitude of program directors was captured in a survey of selected specialties and subspecialties during that 1993-94 academic year. (23)

Miller surveyed 3,090 program directors (70.7 percent response rate) to determine the percentage of new graduates who did not find a full-time position in their specialty or subspecialty. New graduates without full-time jobs ranged from zero for urology to 10.8 percent for pathology. Anesthesiology was reported at 6.6 percent. Perceived difficulty finding a full-time position was reported by more than 20 percent of program directors in anesthesiology, gastroenterology, and plastic surgery programs.

In contrast, directors of programs in family practice, emergency medicine, and geriatrics were optimistic about their graduates and practice options. Pessimism for future downsizing pervaded programs in anesthesiology, gastroenterology, radiology, cardiovascular disease, and plastic surgery. In summary, this survey suggested that market forces were beginning to limit opportunities for some specialists in some regions of the country. (23)

While some specialties, such as radiology, had built a database of employment opportunities yearly, anesthesiology did not have any similar data. (24) In late 1994, recognizing the need to provide a baseline for trends on a specialty-specific basis, the ASA's Physician Resources Committee designed a direct mail survey to appraise perceptions of new anesthesiology graduates.

This initial attempt at an annual assessment was sent to 1,400 graduates in the summer of 1995. At the height of increasing national pessimism and frustration, new graduates, not program directors, were asked about employment opportunities, unemployment, and major issues affecting their career as they perceived it in the 1995 job market. Of the 647 respondents (45 percent response rate), 11 reported unemployment (1.7 percent).

This survey was followed by assessing employment rates for the same new graduate cohort, this time surveying anesthesiology program directors associated with the Society of Academic Anesthesiology Chairs. * A questionnaire was sent to each of 117 program directors in January, 1996. Eighty-three replies (70.9 percent response rate) on 1,205 graduates reported that only 13 (1.1 percent) were unemployed.

How can one reconcile these low unemployment rates from new graduates and also program directors with those of Miller et al? That's remarkably easy. Unemployment rates are determined by what's included in the definition. Miller's estimate of 6.6 percent unemployment rate for anesthesiology graduates in 1993-94 expanded the unemployed definition to include part-time, elective time off for nonmedical interests (to include having a family), working outside the specialty, and locum tenens.

Continuing to respond to widespread concerns of a potentially increasing unemployment rate, the specialty's two national academic organizations representing all program directors in anesthesiology met to collect data during the period up to the end of August, 1996. This cut-off date was selected as it is the latest date for the American Board of Anesthesiology to accept graduating residents into the examination and certification process.

A questionnaire was distributed to 135 program directors (68 percent response rate) a few weeks prior to the end of the 1995-96 academic year. (25) Ninety-two programs returned the survey representing 1,085 graduates, of which 895 were residents (initial class size contained 1,701 residents beginning July 1, 1995). In addition, there were 148 fellows surveyed who were new graduates as of July 1, 1996. Of the entire 1,085 graduates only 29 (2.7 percent) were unemployed. By including individuals taking employment by necessity (locum tenens and other) the rate rises to 4.3 percent.

These most recent data do not support the conclusion that there is major and growing unemployment problem for new anesthesiology graduates. The new annual anesthesiology program directors survey, as well as the graduate survey, will help to create a database for planning by the specialty. As programs begin to downsize and redesign curricula, these longitudinal specialty-specific data will become valuable to physician work force policy discussions about anesthesiology. Perhaps each specialty can learn from this experience of how to build and maintain their own databases for physician work force planning.

Reinventing itself

Anesthesiology, as one of 26 medical specialties and subspecialties, has begun to position itself for ongoing change. The ASA, founded in 1905, became the first medical specialty society to develop and adopt standards of care for its members as early as 1986. Today, more than 30 standards, guidelines, and practice parameters address monitoring standards during surgery, as well as anesthesiologists' direct involvement in patient care before, during, and after surgery.

Utilizing its dual role as generalist/ specialist, anesthesiology has moved beyond an intraoperative only, underrepresented specialty confined to acute care hospital operating rooms. Today, members are redesigning comprehensive practices including ambulatory, perioperative medicine. (26) Pre-anesthesia care clinics, postoperative acute pain management, chronic and palliative pain clinics, and anesthesia services provided in surgeons' and dentists' offices are becoming the practice norm.

The "invisible hand of the marketplace" has put anesthesiologists on the fast track. For example, downsizing by residency programs has occurred from market forces and publicity, more than from public policy or specialty direction. (25) Autonomous, single specialty practices are evolving from solo to group arrangements that are able to provide comprehensive care for populations of patients. Dual role educational flexibility has allowed the specialty to change practices to accommodate both complex acute hospital operations (i.e. organ transplants, specialized cardiac and neurosurgery procedures, neonatal operations, trauma, and other high risk patients) and the rapid emergence of same day surgery programs.

Anesthesiology boasts a new certificate of competence in pain management, unique among medical specialties. With acute and chronic pain therapy as a generalist/specialist entree, anesthesiologists can develop networks with referral physicians and hospital administrative colleagues. For example, many anesthesiology groups are cooperating with hospital partners to offer a comprehensive pain management program responsive to the needs of a community. Anesthesiologists, as perioperative physicians, make rounds in hospitals outside the confines of operating rooms; medically direct preanesthetic clinics; practice high risk, high-technology medicine in acute hospital operating rooms; and provide comprehensive services employing the skills offered by all six subspecialties of anesthesiology. This dual role potential will become increasingly apparent to health care colleagues, as anesthesiologists move beyond the operating room. Additionally, a more informed health care consumer is watching and taking notice. (27) Checking out the Internet for provider information will be normal "background reading" for the younger patient.

Complacency or watchful waiting seems a poor choice for any specialist group. Despite the radical change we are experiencing in daily practice, we must go upstream to reinvigorate the selection of the best and brightest medical students. Quantity of new graduates will never substitute for quality leaders. Quality physicians in the next generation are crucial to the change process of delivering more services to each community. How might we envision our short- and long-term challenges with a creative and innovative focus on young trainees?

Preceptorship and curriculum enhancement

The ASA preceptorship program embraced in the 1970s by teacher/clinicians in community and academic practice can be a useful model to reexamine. Perhaps it could serve as an alternative for medical students in some teaching departments. (28) Medical student externs, paid a modest stipend during breaks between first and second year classes, can reinforce their learning by beginning "hands on" life support skills by training with an experienced teacher/clinician.

Who knows whether they will choose the specialty for a career? However, the experience can serve to introduce the option. In addition, anesthesiology programs can assume more responsibility for teaching life support skills as a mandatory component of the curriculum. Such integrated instruction can begin in the second year with certification in basic life support skills, then move to providing advanced life-support for each student before graduation. (29)

A required component of the medical curriculum can introduce students early to the numerous practice options in anesthesiology. Subsequent fourth year rotations as "anesthesia interns" can offer more hands on exposure to the science and practice of perioperative medicine. Enthusiastic residents and faculty are crucial to learning and discovery. Including medical students in departmental social functions, career discussions, plus "hands-on" experience in clinical areas can expand vistas for medical students as they select career choices.

Moreover, establishing and maintaining quality in a specialty begins with raising the standards for education and training. More comprehensive quality criteria have already been implemented by the Anesthesiology Residency Review Committee (RRC). This accreditation body serves the specialty as an arm of the Accreditation Committee for Graduate Medical Education of the American Medical Association. New criteria for board score performance by residents and minimal clinical experience requirements for each trainee became effective July 1, 1996.10 In addition, the RRC requires prospective approval of increasing the number of residency positions, as is common in many surgical specialties.

Another strategy to recruit high quality AMGs might be to set a goal to "Match 700 by 2000." A specific goal allows all ASA members to come together to sustain and enhance multiple creative options for medical student learning. By raising educational standards using the new quality guidelines by the RRC, anesthesiology residency positions nationally will be reduced. Program attrition and downsizing is already occurring. (30) Such an impartial and quality-based educational approach can only strengthen the specialty. Uncoupling the clinical service needs of the hospital from the education of residents becomes essential to enhancing any level of educational experience.

Clinical services previously provided by the resident work force will require replacement costs to employ non-physician clinicians. (31) Each local environment and graduate education program can determine the mix among replacement personnel (i.e., CRNAs, additional clinical faculty, anesthesiologists' assistants, nurse practitioners, or other physician extenders). Such discussions about replacement costs with medical school deans and academic hospital administrators, although difficult, will continue to highlight effective leadership in academic anesthesiology.

No one should be deceived into thinking that GME federal funding will not decrease. The writing is already on the wall for reducing GME's substantial annual public subsidies ($6 billion) through the Medicare program. Academic medical center leaders need not be defensive, reactive, or surprised by this reduction of public funds. Addressing the Medicare Trust Fund's insolvency will be uppermost on the mind of the newly elected 105th Congress. The vulnerability of the annual GME subsidy is now a given in Washington. Nevertheless, Congress cannot be allowed to ignore the service provision transition costs as residency programs downsize. (31)

Already, the 1996 ASA's House of Delegates has heard testimony on recommendations of COGME, IM, AAMC, and the Pew Commission to reduce the number of residency positions to 110 percent of the number of American medical graduates per year. The long-term focus on program reductions and total residency numbers for most specialties, although painful now, would put American work force policy on a more realistic trajectory. The need for specialists will continue to change radically with the proliferation of managed care. As an example, the Northern California "war zone" of vertically integrated managed care can alert us to the process of intense competition presented by capitation. (15)

Concomitant with recruiting talented, enthusiastic medical students, targeting a "Match of 700 by 2000", and raising the educational standards of the field, anesthesiology can be a leader in the redesign process for adjusting to the supply/ demand equilibrium for the new era of U.S. health care. Additionally, we can expand the health care pie for anesthesiology services beyond intraoperative care. (26) For the first time, anesthesiology enjoys an adequate manpower supply to provide comprehensive anesthesia care.

Additionally, we must implement an additional quality guideline of the RRC. We are obligated to design and implement a practice management curriculum for each anesthesiology residency. Previously, Cantor et al surveyed a national sample of 4,756 allopathic and osteopathic physicians trained in allopathic residencies. Eighty percent of these young physicians reported that their formal medical training did an excellent or good job preparing them for the scientific basis of medical practice. (32) However, fewer than 3 percent reported being well prepared to manage business aspects of practice.

Anesthesiology residents reported the least preparation for practice management (i.e., < 1 percent). The ASA has begun several national seminars and regional refresher courses to overcome the deficit in practice management education. Each residency program will require a basic curriculum to launch the process of postgraduate continuous learning beyond scientific medicine. (33) Market-driven health care reform seems likely to accelerate the urgency for remedial action.

Redesigning for perioperative medicine

The economic paradigm of health care has already shifted from fee-for-service to service-for-a-fee (capitation) in many areas of the U.S. Anesthesiology practices are changing from solo to larger groups. Physicians receiving basic and continuing formal education in medical management will suddenly become essential to the survival of each group practice. Such formal education can be continuing education, not just degree based. Combining the basic and clinical sciences of medicine, the business sciences, and the psychosocial sciences will define physician executives in the 21st Century. (29) These leaders can serve as physician executives to redesign the future roles for all physicians, generalists and specialists.

Many newer options exist to expand medical education outside traditional science. Practice management skills for anesthesiologists can include medically directing operating rooms, ambulatory surgery centers, preanesthetic consultation clinics, and moving beyond anesthesia "block shops" to comprehensive pain centers for the community. The professional practice pie can get bigger and more exciting as physicians add practice management knowledge and competencies to their ability as clinicians. Hopefully, anesthesiologists will not be content to stand and watch as some fight over the ever shrinking pie of conventional inpatient, intraoperative anesthesia services.

Anesthesiology has already improved intraoperative safety and reduced perioperative risks. (17) With additional new skills and visionary leadership, the specialty can offer each community more, not less, "out-of-the-operating room" experiences, managed by anesthesiologists. Serving as community physician and citizen should be the goal for each physician. An attitude of abundance, not scarcity, can prevail as the industry faces the changes of the U.S. health care delivery and funding system. (34)

In clinical practice today, the "Anesthesia Care Team" is used to describe what we do. What about a more future-oriented and global term, such as Integrated Anesthesia Care? (35) These words broaden the concept of clinical care and more accurately describe the reality reaching toward the new millennium.

We are recruiting nurse practitioners and physician assistants in preoperative assessment clinics, psychologists in comprehensive pain management, nonphysician managers to help in business, nurse anesthetists and anesthesiologists' assistants to work with us in different anesthetizing locations, and other uniquelytalented, advanced practice nurses. All of these colleagues help us expand toward integrated anesthesia care. Such diversity, growth in practice size, and operational complexity of comprehensive practice demand a more global vision. Undoubtedly, we are sprinting from acute care hospitals to ambulatory care centers to hospices toward the single best site of care--the home.

Anesthesiologists will increasingly be functioning in integrated networks of care, regionally serving populations of patients. New skills and competencies will be needed and expected if we are to take our place with colleagues. Residents can acquire the rudiments of managing information, working effectively as part of a team, integrating practice guidelines and clinical judgment, and managing outcomes while in training. (36) Most specialties will have to reshape curricula and redesign education programs and academic delivery systems concentrating on fewer trainees. That new reality cannot be all bad. Smaller cohorts of residents, educated more extensively to gain an understanding of managed care issues, will find themselves highly competitive in joining any future practice.

Now is the time for physician leaders to demonstrate commitment and courage as we reinvent our preferred future. Professing to serve each community beyond high technology medicine can only enhance the personal image and self-esteem of physicians. After all, medicine really is our profession to reinvent and continuously improve. Each patient can and should enjoy a healthier and more fulfilling life through the combined efforts of all health professionals.

THE ADVENT OF NON-PHYSICIAN CLINICIANS

Any comprehensive discussion of work force issues in anesthesiology and other specialties becomes incomplete without addressing the role of nonphysician providers. Intraoperative nonphysicians include CRNAs and anesthesiologists' assistants (AAs).The latter are graduate physician assistants, who function only with the direct medical supervision of an anesthesiologist. CRNAs and AAs perform similar intraoperative duties and are recognized by the Health Care Financing Administration as equivalent for purposes of reimbursement under Medicare law. (17) Although educational requirements differ, the CRNAs practice environment is not dissimilar from critical care units, where graduate nurses work in tandem with physician direction. In fact, many CRNAs have critical care experience and may even be certified critical care nurses.

Regardless, the objective for the anesthesia care team (ACT) is the same: Nurses and physicians work cooperatively together for the best patient care outcomes. The other team member (AAs) represents a more recent and smaller cohort, compared to CRNAs. Since 1969, two training sites (Case-Western Reserve University and Emory University) have graduated about 400-500 AAs, who work in 14 states. Anesthesiologists and CRNAs together are still the largest provider groups of about 44,000 nationally.

Today, more than 90 percent of the surgical procedures performed in the U.S. occur at facilities where anesthetics are either administered by an anesthesiologist (physician only) or the ACT is physician-directed. (21) When CRNAs work without medical direction by an anesthesiologist, the setting is rural, the hospital averages less than 100 beds, and fewer than four operations occur per day. (22) As one would predict, such operative procedures are less complex, shorter in duration, and performed on healthier patients. (22) Despite these simpler operations on healthy patients, risks for adverse outcomes are increased when a board certified anesthesiologist is not a member of the hospital medical staff. (18)--Robert W. Vaughan, MD, & M. Sue Vaughan, PhD, RN

FIGURE 1 U.S. Medical Students Shout!

A significant decrease occurred in the percentage of anesthesiology
slots filled by American medical graduates in the second post graduate
years (PGY 2). These decreases were clearly evident in years
1995 and 1996.

% PGY 3 Fill Rate

Year

'91    77
'92    76
'93    67
'94    63
'95    37
'96    17

--Vaughan & Vaughan

Note: Table made from bar graph.

* Zapol: personal communication.

References

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Robert W. Vaughan, MD, is Professor of Anesthesiology at the University of North Carolina School of Medicine, at Chapel Hill. He is Former Chair (1994, '95, '96) of the Physicians Resources (Manpower) Committee for the American Society of Anesthesiologists and can be reached at 919/929-9508, or by fax at 919/929-2442, or via e-mail at [e-mail].

M. Sue Vaughan, PhD, RN, is Clinical Assistant Professor and Research Associate for the Departments of OB/GYN and Health Services Research at the University of North Carolina and Principal of The Cole Vaughan Group in Chapel Hill, North Carolina. She can be reached at 919/929-9508, or by fax at 919/929-2442, or via email at [e-mail].