A career in anesthesiology provides an opportunity for a varied, stimulating and fulfilling practice and has been popular as a specialty choice for graduating medical school students in the U.S. and elsewhere [11]. Residents in anesthesiology report satisfaction with their training [8], and many experienced anesthesiologists remain enthusiastically engaged in their work. Nevertheless, the profession of anesthesiology faces challenges and our survey study evaluated the perceptions of first-year graduates of U.S. anesthesiology residencies on this issue. The main finding was that these early career anesthesiologists perceived challenges fell into three broad themes - workforce competition from non-physician anesthesia providers and unease about external perception of anesthesiologist value, changes in the healthcare system that led to concerns about lower compensation and threats to patient care, and personal stressors including disquiet over burnout and the need to meet professional standards. These results highlight issues for programs and organizations to address. The perceived challenge to employment security posed by CRNAs and the perceived lack of appreciation for anesthesiologist value were most frequently cited. Although both AFs and DEs had similar concerns about the profession of anesthesiology, the relative weighting of their worries was different and may be the reasons behind or a consequence of their decision to pursue or not pursue a fellowship.
Demographic characteristics of AFs and DEs were similar and reflective of the life-stage of typical North American residency graduates. The influence of family factors on the decision to enter fellowship has previously been documented by Khan et al. among Canadian anesthesiology residents [6]. Having children may be a disincentive to fellowship because of the work hours involved, on-call responsibilities, and the unpredictability of these responsibilities. We suggest that implementation of measures to make fellowships more accommodating to anesthesiologists with, or intending to have, children would encourage more residents to consider that path [12]. Such measures might include enhancement of schedule flexibility, more accommodating leave-of-absence policies, support for nursing mothers, and improved access to childcare [13,14,15]. A greater amount of educational debt decreases the likelihood of a physician selecting a post-residency academic position and increases residency graduates interest in anesthesiology groups with an educational debt repayment program [3, 16, 17]. Although student debt was not reported as a major challenge in this study and debt burden was similar among AFs and DEs, those who chose to go directly into independent practice were slightly older, had more dependents, and were more likely to have a spouse who did not work outside the home, factors that may have influenced a perceived imperative to achieve financial security for their families. Although statistically significant, these differences were modest, and it is not clear that such modest differences would be determinative in making such an important life decision. Consistent with previous reports [7], a substantial proportion of respondents were not satisifed with their personal and professional life balance, although DEs expressed greater satisfaction than AFs.
From the perspective of U.S. anesthesiology residency graduates, the greatest challenge to the profession of anesthesiology identified from free-text comments was competition from non-physician anesthesia providers, the subject of more than half of all comments. This level of concern does not appear to be a new phenomenon [18, 19], but its persistence is striking. Of interest, compared to when these cohorts were CA-3 residents [2], AFs in training were slightly more concerned about this workforce competition while DEs were less concerned. We speculate that some DEs had seen first-hand how a highly functioning collaborative practice could work, whereas fellows lacked the real world experience and were apprehensive about their unknown post-fellowship employment. Providing more opportunities for fellows to participate in collaborative practice with advanced practice providers may help ease such concern and better prepare them for the care team they may lead in their future practice. Previous work has demonstrated the vulnerability and discrimination experienced by female anesthesiologists worldwide [20, 21]. Although many female DEs in our study were concerned about a perceived lack of differentiation between anesthesiologists and CRNAs (approximately 60% of CRNAs are female) [22], the proportion relative to other groups was not statistically significant. It was notable that those DEs who practiced predominantly in the care team model in a large practice (i.e., infrequently or never personally administered anesthesia as the sole provider) were more likely to raise a concern about the external perception of anesthesiologist value and a perceived lack of advocacy for the profession [23, 24]. To alleviate the concern, professional organizations and major hospitals could use diverse platforms and channels, including participation in medical conferences, strategic engagement on social media, and featured content in healthcare publications, to spotlight the contributions and expertise of anesthesiologists and foster a broader understanding and appreciation of their role in healthcare.
The choice of fellowship influenced the perception of competition from non-physician anesthesia providers. Advanced training was seen by some as a means to further differentiate anesthesiologists from non-physicians. Subspecialty training in either critical care medicine or cardiac anesthesiology was associated with a lower concern about workforce competition. Critical care medicine practice seems to be sufficiently different from operating room anesthesia that fellows feel assured that their physician subspecialty skills are more difficult to replace. Indeed, we previously documented that anesthesiology residents considered their critical care rotation as one of the most important rotations in clinical anesthesia training [8]. Although nurse practitioners increasingly deliver care in intensive care units, such individuals are usually not CRNAs. We also postulate that the routine integration of echocardiography training into cardiac anesthesiology fellowship helps differentiate the role of the cardiac anesthesiologists from that of the cardiac operating room CRNAs, which results in a decrease in the competition concern. Less easily explained, however, is that pain medicine fellows had the highest concern about workforce competition. Perhaps an explanation lies in the increasing number of non-anesthesiologist physicians and non-physicians who provide care in pain management [25, 26] in the U.S. and thus a heightened sensitivity to this issue among anesthesiology pain medicine fellows and consultants.
Within the second identified theme of healthcare system changes, concerns relating to financial compensation were most prominent. Many responses included specific concerns about decreasing reimbursements and bundled payments. Although female anesthesiologists salaries are 512% lower than those of male anesthesiologists [27] and female anesthesiologists face inequity in clinical practice [28], it was the male respondents in our cohort who were more likely to express concerns about compensation. DEs in large practices who often or exclusively perform their own cases were especially concerned about their renumeration. We speculate that their lack of a multi-room supervisory practice made these anesthesiologists feel vulnerable to identification as an in-room provider, similar to a CRNA or AA, with subsequent concern that they would be compensated at lower rates than those anesthesiologists whose practice model allows them to bill for simultaneous cases. Finally, our data, analyzed according to four U.S. regions of respondent practice location, demonstrated that compared to DEs in the northeastern region, those in the Southeast and West were more concerned about compensation. This may be partly due to regional differences in the anesthesiology workforce and the location-specific ratio of CRNAs to anesthesiologists [29, 30]. Although anesthesiologists are well compensated, our findings suggest that financial challenges are of significant concern at the outset of a career in the profession.
Although respondents had free range to identify any perceived challenges to the profession and to them, it is reassuring and concerning - that primacy of patient welfare was highlighted as the principal challenge by about 8% of respondents. Threats to patient care were identified especially by those in the high acuity subspecialty of cardiac anesthesiology and those in large- and medium-sized groups who frequently or exclusively performed their own cases. One could speculate that this may be reflective of concerns held by those anesthesiologists who are routinely charged with caring for the most complex cases in what they perceive are increasingly corporate systems that prioritize economies and efficiencies.
The findings of our report are consistent with data obtained from senior anesthesiology residents as part of the ABA sequential cross-sectional survey study [2]. Similar themes were identified in that cohort, with work force competition from non-physician anesthesia providers being perceived as the greatest threat to the profession, followed by changes in the healthcare system and personal challenges. AFs, DEs, and senior anesthesiology residents were similarly concerned with undervaluation of anesthesiologists by others and lack of advocacy for physician values, an advocacy role more prominent than in any other medical specialty in the U.S.
As we have discussed in previous publications, our analyses based on repeated cross-sectional surveys are subject to limitations [2, 7, 8]. Of special relevance to the evaluation of perceived challenges to the profession was the potential for respondent bias, possible sources of which include subjective views of themselves, their practice, or the profession, and a deliberate portrayal of a specific view to the ABA. For example, respondents may have been reluctant to talk about their own compensation, but more willing to raise concerns about undervaluation of anesthesiologists. Additionally, although we strived to follow best practices of data collection and analysis, the free-text responses were open to interpretation, especially those that were brief and did not elaborate on the context. Our methodology allowed measurement of the frequency with which concerns were spontaneously expressed but not the prevalence of those concerns within the cohort. Respondents had to identify the greatest challenge facing the profession of anesthesiology; they would not likely have reported all challenges that may have been important to them. Further, our data reflect the views of U.S. anesthesiologists and were collected before the COVID-19 pandemic as part of a repeated cross-sectional study of stable cohorts, and do not reflect views of anesthesiologists outside of the U.S. or changes that may have occurred since the onset of the pandemic. Some of the post-pandemic changes in the U.S. include shortages of both anesthesiologists and CRNAs, upward compensation adjustments because of those shortages, and consolidation and increased corporatization of practices. Future studies could utilize the results of this study to make comparisons about how the challenges and perceptions have changed since the COVID-19 pandemic.
In summary, our data provide insight into the characteristics of AFs and DEs and their perception of challenges to the profession of anesthesiology in the U.S. The demographic characteristics of these two groups were largely similar. Although differences in age and family factors may suggest possible motivations for choosing fellowship or not, the importance of these small differences is uncertain. Our investigation of free-text responses to the question of the greatest challenge facing anesthesiology highlighted three major themes in descending order of frequency: workforce competition, healthcare system changes, and personal challenges. Members of the AF and DE groups shared these same concerns, but the relative weighting of these concerns was different and influenced by demographic and professional variables such as gender, fellowship subspecialty, and independent practice characteristics. These physicians represent the next generation of anesthesiologists in the U.S., who will drive the future directions of the specialty. We hope that our identification of the challenges they face and their concerns will inform advocacy and policies at programmatic and professional organizational levels.
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Comparing characteristics and perspectives of U.S. anesthesiology fellows in training and anesthesiologists in their first ... - BMC Medical Education