- Email: [email protected]
What is an anesthesiology resident worth?
Journal of Clinical Anesthesia (2009) 21, 317–321
Original contribution
What is an anesthesiology resident worth? Marisa H. Ferrera MD (Anesthesiology Resident)⁎, Shawn T. Beaman MD (Assistant Professor), David G. Metro MD (Associate Professor), Linda J. Handley MHA (Project Manager), James E. Walker Jr. BS (Education Administrator and Director of Special Projects) Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA Received 14 January 2008; revised 17 November 2008; accepted 4 December 2008
Keywords: Anesthesiologists: education; Anesthesiology resident; Certified registered nurse-anesthetist, costs; Manpower; Operating room staffing; Remuneration
Abstract Study Objective: To determine the cost of replacing an anesthesiology resident with a certified registered nurse anesthetist (CRNA) for equal operating room (OR) work. Design: Retrospective financial analysis. Setting: Academic anesthesiology department. Participants: Clinical anesthesia (CA)-1 through CA-3 residents. Measurements: Cost of replacing anesthesiology residents with CRNAs for equal OR work was determined. Main Results: The cost of replacing one anesthesiology resident with a CRNA for the same number of OR hours ranged from $9,940.32 to $43,300 per month ($106,241.68 to $432,937.50 per yr). Numbers varied depending on the CRNA pay scale and whether the calculations were based on the number of OR hours worked at our residency program or OR hours worked in a maximum duty hour model. Conclusions: A CRNA is paid substantially more per OR hour worked, at all pay levels, than an anesthesiology resident. © 2009 Elsevier Inc. All rights reserved.
1. Introduction While the primary goal of anesthesiology residency is to provide education and clinical training, residents contribute significantly to the clinical workload of their departments. In 1998, Pisetsky et al [1] performed a cost analysis to determine the cost of replacing anesthesiology residents with alternate care providers, including certified registered nurse-anesthetists (CRNAs). They determined that the cost ⁎ Corresponding author. Tel.: +1 412 692 4506; fax: +1 412 692 4515. E-mail address: [email protected] (M.H. Ferrera). 0952-8180/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2008.12.016
of substitution (replacement labor minus net resident cost) for clinical work averaged $51,000 per resident per year. In 1999, Franzini and Berry [2] estimated that each resident supplied a total of $103,436 in teaching and clinical services per year, and required only $75,070 in resident training costs. The analyses performed by Pisetsky et al and Franzini and Berry were done at a time when there was an abundance of anesthesiologists. At that time, the focus of residency applicants shifted from specialty fields toward primary care, resulting in a decline in applications for anesthesiology programs in the mid-1990s. The number of unfilled positions peaked at 622 in 1996. It was not until 2002 that the number
318 of vacant positions fell below 100, reaching its lowest number of 24 in 2006.1 The prior reduction in resident applications has, since 2001, resulted in a shortage of anesthesia providers. In 2002, there was an estimated 3.2% to 11.0% deficiency of anesthesiologists nationwide [3]. Based on a yearly growth rate of 1.5% to 2% of graduating anesthesiology residents, Schubert et al [3] projected that the shortage of anesthesiologists would continue through 2015. The increased need for anesthesia providers resulted in increased salaries for both physicians and CRNAs. These salary increases greatly impacted the financial status of both anesthesiology departments and the institutions from which they received support. In light of the increased salaries paid to all anesthesia providers, particularly CRNAs, we performed an updated financial analysis calculating the cost of replacing a resident with a CRNA for equal OR time.
2. Materials and methods The CA-1 through CA-3 schedules of graduates of our program in 2006 were reviewed to determine the average OR hours worked per month and per year by each resident. Calculations made were based only on time spent in the OR for each general or subspecialty rotation completed. For “regional” months, the resident who performed the preoperative regional technique also provided the intraoperative care, and these months were therefore considered OR rotations. Non-OR rotations [critical care medicine (CCM), post-anesthesia care unit (PACU), and acute and chronic pain] were counted as zero hours in the OR for the purpose of this study. We determined the average number of OR hours worked for each general, subspecialty, or advanced clinical rotation. Each day in the OR was counted as 10.5 hours because residents were expected to be available from 0630 to 1700 at our institution. Each weekday call was 16 hours, from 1500 to 0700. Weekend call was 24 hours, from 0700 to 0700. These hours held true for all rotations except the obstetrical rotation, where the following adjustments were made due to different scheduling practices. The OR weekday was 9 hours (from 0700 to 1600), Friday night call was 18 hours (from 1500 to 0900), weekend day shift was 8 hours (from 0900 to 1700), and weekend nights were 16 hours on Saturday (from 1700 to 0900) or 14 hours on Sunday (from 1700 to 0700). We determined the average number of days spent in the OR, on weekday call, or on weekend call for each rotation by reviewing the monthly schedules of each resident. Then, to determine the average number of hours for each rotation, 1 Grogono AW. The national residency matching program results for 2006: recruitment shifts to the PG1 year. ASA Newsletter, May 2006. Park Ridge, IL: Americation Society of Anesthesiologistst, 2006.
M.H. Ferrera et al. each of the shifts were multiplied by our pre-determined shift durations. Having assigned an average number of hours worked for each rotation, these values were used to calculate the average number of hours worked by each resident per month based on each resident's individual yearly rotation schedule. At our university and in accordance with the Accreditation Council for Graduate Medical Education (ACGME) program requirements, residents spent 20 of the first 24 months in the OR providing hands-on care. Non-OR rotations included two months in CCM, one month in chronic pain management, and two weeks each in acute pain and PACU. Although the distribution of non-OR rotations varied for each resident during the first two years, our calculations were based on the assumption that each resident spent 10 of 12 months in the OR during each of the CA-1 and CA-2 years. We then multiplied these 10 months by the average number of hours worked in the OR per month during the CA-1 and CA-2 years to calculate the average number of OR hours worked per year. CA-3 residents were able to select a combination of OR and non-OR rotations to complete their anesthesiology residency. Not all CA-3 residents were involved in OR rotations for the entire 12 months, but a majority were. To determine the average number of OR hours worked per year by CA-3 residents, calculations were made as if all residents had spent the entire year in OR rotations, multiplying the average hours worked per month in the OR by 12. This process most closely approximated scheduling in our program since residents seldom chose research or non-OR rotations during their CA-3 year. The calculations were therefore based on the assumption that CA-3 residents spent all of their time in the OR, allowing the maximum value of a resident to be determined. Time involved in educational activities was subtracted from the OR working hours. These activities included level-specific, weekly one-hour lectures for the CA-1, CA2, and CA-3 classes during all rotations as well as rotation specific lectures. Monthly 1.5-hour, problem-based learning discussions and 4-hour educational sessions held in the simulator 4 times a year comprised the other didactics. Grand rounds, journal club, and other lectures were not excluded from the OR hours because they took place outside of the OR workday. For our calculations, the cost of a CRNA to replace resident OR time was calculated using the three pay scales that existed at our institution. Department CRNAs were divided into new and experienced CRNAs, receiving $48.50 or $69 per hour, respectively. Locum CRNAs were paid $125 per hour. Benefits were also given to hospital CRNAs, and overtime was paid at time-and-a-half for work over 40 hours per week. Table 1 shows CRNA benefits. Benefits equaled an additional 23.3% of the hospital CRNAs' salary. Vacation time was subtracted from the calculations for locum CRNAs, but not from hospital CRNAs, given that the vacation allowance between residents and hospital CRNAs
Value of an anesthesiology resident
319
Table 1 Fringe benefits of CRNAs and residents as percentage of salary
Dental Employee assistance FICA Health insurance Life Long-term disability Short-term disability Pension Tuition Worker's compensation Total
CRNA
Resident
0.3 0.3 7.5 8.7 0.3 0.4 0.1 5.6 0.1 0 23.3
0.3 0 7.65 15.76 0.08 0.17 0 0 0 1.61 25.6
CRNA = certified registered nurse-anesthetist; FICA = Federal Insurance Contributions Act. FICA is a federal tax deducted from paychecks in the United States to pay for Social Security.
rotation for these years. Results of the average OR hours worked per year in our program were 1,848.7, 1,992.4, and 2,388 hours, respectively. For our program, the average of these numbers equaled 194.37 OR hours per month (2,076.37 OR hrs per yr) over three years. For locum CRNAs, the calculated average OR hours to be replaced per year was 1,916.56 hours, which excluded 159.81 vacation hours. The averages obtained over the threeyear period were the numbers used to calculate hourly pay if a CRNA were to replace a resident. For the maximum duty hour model, the average OR hours per month was 346.4 hours (3,751.5 hrs per yr). Subtracting 288 vacation hours for the locums group resulted in 3,463.5 OR hours per year that needed to be replaced. Tables 4 and 5 give the replacement cost per month and per year of resident OR activity.
4. Discussion approximated each other. Residents received three weeks of vacation and one week of meeting time each year. Because 89% (32 of 36) of the months were spent in the OR at our institution, we calculated that 89% of vacation was taken during OR rotations. Therefore, 3.56 weeks per year was subtracted from locum CRNAs' OR hours. We also determined the cost of paying CRNAs for a maximum work hour schedule allowed by the ACGME, defined as 80 hours per week. ACGME required 3.5 non-OR months during training, including two months in CCM, one month in pain management, and two weeks in PACU. These months were counted as zero hours worked in the OR in our calculations. ACGME did not specifically require didactics during work hours, so we assumed that the full 80 hours per week were in the OR. Ninety-percent (32.5 of 36 OR mos), or 3.6 weeks per year of OR time, were subtracted in the maximum duty hour model for vacation.
3. Results For the CA-1, CA-2, and CA-3 years, the average number of OR hours worked per month equaled 184.87, 199.24, and 199 hours, respectively. This number was an average of 45 hours per week over a three-year period. Tables 2 and 3 show the average number of hours worked per month in each OR
Table 2
To determine the financial impact of anesthesiology residents, the replacement cost of an anesthesiology resident with a CRNA for equivalent OR hours was calculated. At our institution, the amount ranged from $106,000 to $240,000 per resident per year. Anesthesiology residents in our program worked in the OR an average of 45 hours per week over a three-year period. Realizing that residents at other programs potentially worked significantly more hours compared with those at our university, we also evaluated the replacement cost in a maximum duty hour model. The sum ranged from $227,000 to $433,000 per resident per year, assuming an 80-hour work week. We used a predetermined number of hours that each resident worked during “shifts” for our calculations. This methodology was chosen because even if a resident was relieved from OR duties prior to the end of the defined times, a CRNA replacing that resident would have been paid for the entire shift. If CRNAs were relieved early from direct clinical care at our institution, they remained available and were paid until their scheduled end time. The staffing models at the sites at which residents rotated included these defined hours in order to perform the contracted clinical activities. In calculating the replacement cost of resident work, our methodology included paying CRNAs for overtime. It is true that hiring additional CRNA staff would have reduced our projected replacement cost by avoiding overtime and locum
CA-1/CA-2 average number of operating room (OR) hours worked per month for each rotation
General OR A
General OR B
General OR C
General OR D
General OR E
Regional C
188.94
192.01
219.17
174.17
173.67
240.67
Liver transplant 182.23
Pediatric 219.67
Thoracic 195.64
Cardiac 203.42
Obstetrics 160
Neurosurgical 201.22
CA-1, CA-2 = anesthesia resident in the first and second clinical year, respectively.
320 Table 3
M.H. Ferrera et al. CA-3 average number of operating room (OR) hours worked per month for each rotation
ACT A
ACT B
ACT D
ACT E
ACT F
Pediatrics
Obstetrics
190.5
211.84
205.67
173.67
231.92
219.67
134.02
Cardiac A 208.46
Cardiac B 231.75
Cardiac D 258.17
Regional C 214.42
Regional D 218.8
Neurosurgical 201.42
Liver Transplant 109.17
The hours for problem-based learning discussions and simulator sessions were not yet subtracted from the numbers in Table 2 or Table 3. Alphabetical letters denote different hospital sites. CA-3 = anesthesia resident in the third clinical year; ACT = advanced clinical track.
costs. However, our institution already relied heavily on overtime pay and locum CRNAs due to difficulty encountered with CRNA recruitment. Therefore, a model allowing for overtime pay and locum costs was the most realistic one for replacing the resident workload. Our cost analysis considered only replacement cost for time spent in the OR. Several other factors influence the overall financial implications, which were not taken into account in this analysis. These factors include resident clinical activity outside of the OR, staffing and reimbursement, source of anesthesia provider salaries, and comprehensive cost of an anesthesiology residency program to a department. Anesthesiology residents provided clinical services outside of the OR that were not provided by CRNAs. At our institution, CRNAs did not participate in the preoperative evaluation clinic, the pain clinic, or in CCM. The residents' clinical duties outside of the OR would have to be replaced by other providers, such as physician's assistants or advanced practice nurses, which would further increase the value of resident replacement cost. Residents were also involved in educational activities for medical students. The above calculations for the hours worked at our institution underestimate resident value in this regard. Faculty staffing for ORs varied depending on whether the faculty member worked with anesthesiology residents or CRNAs. In accordance with ACGME requirements, resident to faculty staffing was 2:1. If a faculty member was assigned only to CRNAs, the staffing could
Table 4 Replacement cost per year of resident operating room (OR) activity New CRNA Experienced LOCUMS CRNA Our program baseline Our program + benefits Max hours baseline Max hours + benefits
$106,241.68 $151,147.95 $239,570.00 $130,995.99 $186,365.42 $227,438.33 $323,572.05 $432,937.50 $280,431.46 $398,964.34 -
CRNA = certified registered nurse-anesthetist; LOCUMS = locum tenens CRNA; Max = maximum.
potentially be 4:1, requiring fewer attendings to run the same number of ORs. This differential in cost was not explored in this analysis. The source of resident and CRNA salaries varies among anesthesiology departments. At our institution, the majority of resident salaries are paid with government funds. However, if the number of residents accepted by the program exceeds the allotted number of funded residency positions, the anesthesiology department or the hospital absorbs the costs. While it is true that our institution receives over $140,000 per year per resident, this figure does not necessarily transfer to direct monetary support of the resident, residency program, or the department. CRNA salaries at our university are provided by both the department and the hospital. Tremper et al [4] showed that 86 of 128 anesthesiology programs participating in a survey employed CRNAs. One third of the programs that employed CRNAs used approximately 50% of their institutional support for CRNA salaries [4]. The cost of direct faculty clinical supervision, the cost of preparing and providing educational activities, and administrative costs are other aspects to consider when determining the total cost of residency training. Taking these factors into account, Franzini and Berry [2] estimated that, in 1999, the total cost of an anesthesiology program was $75,070 per resident per year. This number could have large variation based on the structure and size of the residency, administrative arrangements, support from hospital or university resources, and the extent of faculty involvement. We did not attempt to quantify this number in our analysis.
Table 5 Replacement cost per month of resident operating room (OR) activity New CRNA Experienced LOCUMS CRNA Our program baseline $9,940.32 Our program $12,256.42 + benefits Max hours baseline $21,000.50 Max hours $25,893.62 + benefits
$14,141.90 $17,436.96
$24,296.25 -
$29,877.00 $36,838.34
$43,300.00 -
CRNA = certified registered nurse-anesthetist; LOCUMS = locum tenens CRNA; Max = maximum.
Value of an anesthesiology resident At our program, the average resident salary per year from the CA-1 to CA-3 year was $41,089. With benefits, the average was $53,884. The cost difference for a CRNA for equal OR time was $65,152 to $391,848 per year without benefits, and it was $77,112 to $379,054 per year with benefits. Our study focuses on replacement cost for equivalent OR time and provides an updated analysis showing the financial benefit of anesthesiology residents to their department. While the cost savings shown in our analysis are real, the beneficiary of the savings will vary from institution to institution based on their current level of institutional support.
321
References [1] Pisetsky MA, Lubarsky DA, Capehart BP, Lineberger CK, Reves JG. Valuing the work performed by anesthesiology residents and the financial impact on teaching hospitals in the United States of a reduced anesthesia residency program size. Anesth Analg 1998;87:245-54. [2] Franzini L, Berry JM. A cost-construction model to assess the total cost of an anesthesiology residency program. Anesthesiology 1999;90: 257-68. [3] Schubert A, Eckhout G Jr, Tremper K. An updated view of the national anesthesia personnel shortfall. Anesth Analg 2003;96:207-14. [4] Tremper KK, Shanks A, Morris M. Trends in the financial status of United States anesthesiology training programs: 2000 to 2004. Anesth Analg 2006;102:517-23.
Original contribution
What is an anesthesiology resident worth? Marisa H. Ferrera MD (Anesthesiology Resident)⁎, Shawn T. Beaman MD (Assistant Professor), David G. Metro MD (Associate Professor), Linda J. Handley MHA (Project Manager), James E. Walker Jr. BS (Education Administrator and Director of Special Projects) Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA Received 14 January 2008; revised 17 November 2008; accepted 4 December 2008
Keywords: Anesthesiologists: education; Anesthesiology resident; Certified registered nurse-anesthetist, costs; Manpower; Operating room staffing; Remuneration
Abstract Study Objective: To determine the cost of replacing an anesthesiology resident with a certified registered nurse anesthetist (CRNA) for equal operating room (OR) work. Design: Retrospective financial analysis. Setting: Academic anesthesiology department. Participants: Clinical anesthesia (CA)-1 through CA-3 residents. Measurements: Cost of replacing anesthesiology residents with CRNAs for equal OR work was determined. Main Results: The cost of replacing one anesthesiology resident with a CRNA for the same number of OR hours ranged from $9,940.32 to $43,300 per month ($106,241.68 to $432,937.50 per yr). Numbers varied depending on the CRNA pay scale and whether the calculations were based on the number of OR hours worked at our residency program or OR hours worked in a maximum duty hour model. Conclusions: A CRNA is paid substantially more per OR hour worked, at all pay levels, than an anesthesiology resident. © 2009 Elsevier Inc. All rights reserved.
1. Introduction While the primary goal of anesthesiology residency is to provide education and clinical training, residents contribute significantly to the clinical workload of their departments. In 1998, Pisetsky et al [1] performed a cost analysis to determine the cost of replacing anesthesiology residents with alternate care providers, including certified registered nurse-anesthetists (CRNAs). They determined that the cost ⁎ Corresponding author. Tel.: +1 412 692 4506; fax: +1 412 692 4515. E-mail address: [email protected] (M.H. Ferrera). 0952-8180/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2008.12.016
of substitution (replacement labor minus net resident cost) for clinical work averaged $51,000 per resident per year. In 1999, Franzini and Berry [2] estimated that each resident supplied a total of $103,436 in teaching and clinical services per year, and required only $75,070 in resident training costs. The analyses performed by Pisetsky et al and Franzini and Berry were done at a time when there was an abundance of anesthesiologists. At that time, the focus of residency applicants shifted from specialty fields toward primary care, resulting in a decline in applications for anesthesiology programs in the mid-1990s. The number of unfilled positions peaked at 622 in 1996. It was not until 2002 that the number
318 of vacant positions fell below 100, reaching its lowest number of 24 in 2006.1 The prior reduction in resident applications has, since 2001, resulted in a shortage of anesthesia providers. In 2002, there was an estimated 3.2% to 11.0% deficiency of anesthesiologists nationwide [3]. Based on a yearly growth rate of 1.5% to 2% of graduating anesthesiology residents, Schubert et al [3] projected that the shortage of anesthesiologists would continue through 2015. The increased need for anesthesia providers resulted in increased salaries for both physicians and CRNAs. These salary increases greatly impacted the financial status of both anesthesiology departments and the institutions from which they received support. In light of the increased salaries paid to all anesthesia providers, particularly CRNAs, we performed an updated financial analysis calculating the cost of replacing a resident with a CRNA for equal OR time.
2. Materials and methods The CA-1 through CA-3 schedules of graduates of our program in 2006 were reviewed to determine the average OR hours worked per month and per year by each resident. Calculations made were based only on time spent in the OR for each general or subspecialty rotation completed. For “regional” months, the resident who performed the preoperative regional technique also provided the intraoperative care, and these months were therefore considered OR rotations. Non-OR rotations [critical care medicine (CCM), post-anesthesia care unit (PACU), and acute and chronic pain] were counted as zero hours in the OR for the purpose of this study. We determined the average number of OR hours worked for each general, subspecialty, or advanced clinical rotation. Each day in the OR was counted as 10.5 hours because residents were expected to be available from 0630 to 1700 at our institution. Each weekday call was 16 hours, from 1500 to 0700. Weekend call was 24 hours, from 0700 to 0700. These hours held true for all rotations except the obstetrical rotation, where the following adjustments were made due to different scheduling practices. The OR weekday was 9 hours (from 0700 to 1600), Friday night call was 18 hours (from 1500 to 0900), weekend day shift was 8 hours (from 0900 to 1700), and weekend nights were 16 hours on Saturday (from 1700 to 0900) or 14 hours on Sunday (from 1700 to 0700). We determined the average number of days spent in the OR, on weekday call, or on weekend call for each rotation by reviewing the monthly schedules of each resident. Then, to determine the average number of hours for each rotation, 1 Grogono AW. The national residency matching program results for 2006: recruitment shifts to the PG1 year. ASA Newsletter, May 2006. Park Ridge, IL: Americation Society of Anesthesiologistst, 2006.
M.H. Ferrera et al. each of the shifts were multiplied by our pre-determined shift durations. Having assigned an average number of hours worked for each rotation, these values were used to calculate the average number of hours worked by each resident per month based on each resident's individual yearly rotation schedule. At our university and in accordance with the Accreditation Council for Graduate Medical Education (ACGME) program requirements, residents spent 20 of the first 24 months in the OR providing hands-on care. Non-OR rotations included two months in CCM, one month in chronic pain management, and two weeks each in acute pain and PACU. Although the distribution of non-OR rotations varied for each resident during the first two years, our calculations were based on the assumption that each resident spent 10 of 12 months in the OR during each of the CA-1 and CA-2 years. We then multiplied these 10 months by the average number of hours worked in the OR per month during the CA-1 and CA-2 years to calculate the average number of OR hours worked per year. CA-3 residents were able to select a combination of OR and non-OR rotations to complete their anesthesiology residency. Not all CA-3 residents were involved in OR rotations for the entire 12 months, but a majority were. To determine the average number of OR hours worked per year by CA-3 residents, calculations were made as if all residents had spent the entire year in OR rotations, multiplying the average hours worked per month in the OR by 12. This process most closely approximated scheduling in our program since residents seldom chose research or non-OR rotations during their CA-3 year. The calculations were therefore based on the assumption that CA-3 residents spent all of their time in the OR, allowing the maximum value of a resident to be determined. Time involved in educational activities was subtracted from the OR working hours. These activities included level-specific, weekly one-hour lectures for the CA-1, CA2, and CA-3 classes during all rotations as well as rotation specific lectures. Monthly 1.5-hour, problem-based learning discussions and 4-hour educational sessions held in the simulator 4 times a year comprised the other didactics. Grand rounds, journal club, and other lectures were not excluded from the OR hours because they took place outside of the OR workday. For our calculations, the cost of a CRNA to replace resident OR time was calculated using the three pay scales that existed at our institution. Department CRNAs were divided into new and experienced CRNAs, receiving $48.50 or $69 per hour, respectively. Locum CRNAs were paid $125 per hour. Benefits were also given to hospital CRNAs, and overtime was paid at time-and-a-half for work over 40 hours per week. Table 1 shows CRNA benefits. Benefits equaled an additional 23.3% of the hospital CRNAs' salary. Vacation time was subtracted from the calculations for locum CRNAs, but not from hospital CRNAs, given that the vacation allowance between residents and hospital CRNAs
Value of an anesthesiology resident
319
Table 1 Fringe benefits of CRNAs and residents as percentage of salary
Dental Employee assistance FICA Health insurance Life Long-term disability Short-term disability Pension Tuition Worker's compensation Total
CRNA
Resident
0.3 0.3 7.5 8.7 0.3 0.4 0.1 5.6 0.1 0 23.3
0.3 0 7.65 15.76 0.08 0.17 0 0 0 1.61 25.6
CRNA = certified registered nurse-anesthetist; FICA = Federal Insurance Contributions Act. FICA is a federal tax deducted from paychecks in the United States to pay for Social Security.
rotation for these years. Results of the average OR hours worked per year in our program were 1,848.7, 1,992.4, and 2,388 hours, respectively. For our program, the average of these numbers equaled 194.37 OR hours per month (2,076.37 OR hrs per yr) over three years. For locum CRNAs, the calculated average OR hours to be replaced per year was 1,916.56 hours, which excluded 159.81 vacation hours. The averages obtained over the threeyear period were the numbers used to calculate hourly pay if a CRNA were to replace a resident. For the maximum duty hour model, the average OR hours per month was 346.4 hours (3,751.5 hrs per yr). Subtracting 288 vacation hours for the locums group resulted in 3,463.5 OR hours per year that needed to be replaced. Tables 4 and 5 give the replacement cost per month and per year of resident OR activity.
4. Discussion approximated each other. Residents received three weeks of vacation and one week of meeting time each year. Because 89% (32 of 36) of the months were spent in the OR at our institution, we calculated that 89% of vacation was taken during OR rotations. Therefore, 3.56 weeks per year was subtracted from locum CRNAs' OR hours. We also determined the cost of paying CRNAs for a maximum work hour schedule allowed by the ACGME, defined as 80 hours per week. ACGME required 3.5 non-OR months during training, including two months in CCM, one month in pain management, and two weeks in PACU. These months were counted as zero hours worked in the OR in our calculations. ACGME did not specifically require didactics during work hours, so we assumed that the full 80 hours per week were in the OR. Ninety-percent (32.5 of 36 OR mos), or 3.6 weeks per year of OR time, were subtracted in the maximum duty hour model for vacation.
3. Results For the CA-1, CA-2, and CA-3 years, the average number of OR hours worked per month equaled 184.87, 199.24, and 199 hours, respectively. This number was an average of 45 hours per week over a three-year period. Tables 2 and 3 show the average number of hours worked per month in each OR
Table 2
To determine the financial impact of anesthesiology residents, the replacement cost of an anesthesiology resident with a CRNA for equivalent OR hours was calculated. At our institution, the amount ranged from $106,000 to $240,000 per resident per year. Anesthesiology residents in our program worked in the OR an average of 45 hours per week over a three-year period. Realizing that residents at other programs potentially worked significantly more hours compared with those at our university, we also evaluated the replacement cost in a maximum duty hour model. The sum ranged from $227,000 to $433,000 per resident per year, assuming an 80-hour work week. We used a predetermined number of hours that each resident worked during “shifts” for our calculations. This methodology was chosen because even if a resident was relieved from OR duties prior to the end of the defined times, a CRNA replacing that resident would have been paid for the entire shift. If CRNAs were relieved early from direct clinical care at our institution, they remained available and were paid until their scheduled end time. The staffing models at the sites at which residents rotated included these defined hours in order to perform the contracted clinical activities. In calculating the replacement cost of resident work, our methodology included paying CRNAs for overtime. It is true that hiring additional CRNA staff would have reduced our projected replacement cost by avoiding overtime and locum
CA-1/CA-2 average number of operating room (OR) hours worked per month for each rotation
General OR A
General OR B
General OR C
General OR D
General OR E
Regional C
188.94
192.01
219.17
174.17
173.67
240.67
Liver transplant 182.23
Pediatric 219.67
Thoracic 195.64
Cardiac 203.42
Obstetrics 160
Neurosurgical 201.22
CA-1, CA-2 = anesthesia resident in the first and second clinical year, respectively.
320 Table 3
M.H. Ferrera et al. CA-3 average number of operating room (OR) hours worked per month for each rotation
ACT A
ACT B
ACT D
ACT E
ACT F
Pediatrics
Obstetrics
190.5
211.84
205.67
173.67
231.92
219.67
134.02
Cardiac A 208.46
Cardiac B 231.75
Cardiac D 258.17
Regional C 214.42
Regional D 218.8
Neurosurgical 201.42
Liver Transplant 109.17
The hours for problem-based learning discussions and simulator sessions were not yet subtracted from the numbers in Table 2 or Table 3. Alphabetical letters denote different hospital sites. CA-3 = anesthesia resident in the third clinical year; ACT = advanced clinical track.
costs. However, our institution already relied heavily on overtime pay and locum CRNAs due to difficulty encountered with CRNA recruitment. Therefore, a model allowing for overtime pay and locum costs was the most realistic one for replacing the resident workload. Our cost analysis considered only replacement cost for time spent in the OR. Several other factors influence the overall financial implications, which were not taken into account in this analysis. These factors include resident clinical activity outside of the OR, staffing and reimbursement, source of anesthesia provider salaries, and comprehensive cost of an anesthesiology residency program to a department. Anesthesiology residents provided clinical services outside of the OR that were not provided by CRNAs. At our institution, CRNAs did not participate in the preoperative evaluation clinic, the pain clinic, or in CCM. The residents' clinical duties outside of the OR would have to be replaced by other providers, such as physician's assistants or advanced practice nurses, which would further increase the value of resident replacement cost. Residents were also involved in educational activities for medical students. The above calculations for the hours worked at our institution underestimate resident value in this regard. Faculty staffing for ORs varied depending on whether the faculty member worked with anesthesiology residents or CRNAs. In accordance with ACGME requirements, resident to faculty staffing was 2:1. If a faculty member was assigned only to CRNAs, the staffing could
Table 4 Replacement cost per year of resident operating room (OR) activity New CRNA Experienced LOCUMS CRNA Our program baseline Our program + benefits Max hours baseline Max hours + benefits
$106,241.68 $151,147.95 $239,570.00 $130,995.99 $186,365.42 $227,438.33 $323,572.05 $432,937.50 $280,431.46 $398,964.34 -
CRNA = certified registered nurse-anesthetist; LOCUMS = locum tenens CRNA; Max = maximum.
potentially be 4:1, requiring fewer attendings to run the same number of ORs. This differential in cost was not explored in this analysis. The source of resident and CRNA salaries varies among anesthesiology departments. At our institution, the majority of resident salaries are paid with government funds. However, if the number of residents accepted by the program exceeds the allotted number of funded residency positions, the anesthesiology department or the hospital absorbs the costs. While it is true that our institution receives over $140,000 per year per resident, this figure does not necessarily transfer to direct monetary support of the resident, residency program, or the department. CRNA salaries at our university are provided by both the department and the hospital. Tremper et al [4] showed that 86 of 128 anesthesiology programs participating in a survey employed CRNAs. One third of the programs that employed CRNAs used approximately 50% of their institutional support for CRNA salaries [4]. The cost of direct faculty clinical supervision, the cost of preparing and providing educational activities, and administrative costs are other aspects to consider when determining the total cost of residency training. Taking these factors into account, Franzini and Berry [2] estimated that, in 1999, the total cost of an anesthesiology program was $75,070 per resident per year. This number could have large variation based on the structure and size of the residency, administrative arrangements, support from hospital or university resources, and the extent of faculty involvement. We did not attempt to quantify this number in our analysis.
Table 5 Replacement cost per month of resident operating room (OR) activity New CRNA Experienced LOCUMS CRNA Our program baseline $9,940.32 Our program $12,256.42 + benefits Max hours baseline $21,000.50 Max hours $25,893.62 + benefits
$14,141.90 $17,436.96
$24,296.25 -
$29,877.00 $36,838.34
$43,300.00 -
CRNA = certified registered nurse-anesthetist; LOCUMS = locum tenens CRNA; Max = maximum.
Value of an anesthesiology resident At our program, the average resident salary per year from the CA-1 to CA-3 year was $41,089. With benefits, the average was $53,884. The cost difference for a CRNA for equal OR time was $65,152 to $391,848 per year without benefits, and it was $77,112 to $379,054 per year with benefits. Our study focuses on replacement cost for equivalent OR time and provides an updated analysis showing the financial benefit of anesthesiology residents to their department. While the cost savings shown in our analysis are real, the beneficiary of the savings will vary from institution to institution based on their current level of institutional support.
321
References [1] Pisetsky MA, Lubarsky DA, Capehart BP, Lineberger CK, Reves JG. Valuing the work performed by anesthesiology residents and the financial impact on teaching hospitals in the United States of a reduced anesthesia residency program size. Anesth Analg 1998;87:245-54. [2] Franzini L, Berry JM. A cost-construction model to assess the total cost of an anesthesiology residency program. Anesthesiology 1999;90: 257-68. [3] Schubert A, Eckhout G Jr, Tremper K. An updated view of the national anesthesia personnel shortfall. Anesth Analg 2003;96:207-14. [4] Tremper KK, Shanks A, Morris M. Trends in the financial status of United States anesthesiology training programs: 2000 to 2004. Anesth Analg 2006;102:517-23.