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Shortage of anesthetists: Real or artificial?
Shortage of Anesthetists: Real or Artificial? JAMES
Most medical manpower surveys reveal a lack of anesthesiologists and anesthetic technicians in this country. An exact definition of the need is obscure but concern has been expressed in many quarters. The output from nurse anesthesia training schools has increased as has the number of trainees in approved residencies in anesthesiology, but little hope has been expressed that the products of these programs can meet future needs. Furthermore, only 70 per cent of the available residency positions are filled. Projection for the future is a continuing inadequate number, even if the present pace of recruitment of physicians into the specialty is doubled or tripled. Perhaps the best indices of the need are apparent to the directors of residency programs. These indices are the number of requests received for anesthesiologists and the number of positions from which each resident completing his t’raining has to choose. He has complete freedom of choice as to geographic location, type of practice, and category of hospital. The beginning incomes are handsome, although not as good as can ultimately be gained by practitioners in many other specialties. Even nurse anesthetists today command salaries ranging as high as $15,000 yearly. Despite the present shortage and bleak future, a discerning observer can hardly overlook the fact that a majority of anesthesiologists and nurse technicians are not fulfilling their potential. Given the opportunity, most could increase and many could double their case loads. Some are satisfied with this state of affairs, but most are not. The directors of many training programs are frustrated over the obvious inefficient use of their staff and the resulting slow progress of many of their trainees. In hospitals with too few st,aff anesthetists, residents often must remain in the operating room constantly to “get the schedule done” to the detriment of their training program;
From the Department of Anesthesia, Northwestern versity Medical School, Chicago, Illinois 60611. Vol. 117, May 1969
Uni-
E. ECKENHOFF,
M.D.,
Chicago,
Illinois
yet’, at the end of the day they may have accomplished relatively little. At one time anesthesiologists were essentially technicians, appearing in the operating room in the morning, anest’hetizing patients without having seen them beforehand and not seeing them again after operation, and leaving the hospital as soon as the operative schedule was completed. This is still the daily rout’ine of the nurse technician and also of some anesthesiologists who choose to keep it this way. Physician technicians are not peculiar to anest,hesia. There are a host of physicians in many specialties whose daily activities have fallen to a technical level. Today’s anesthesiologist is encouraged to be something considerably more than a technician. He carefully examines the patient and his record the day before the operation. His activity should be viewed as that of one of a series of physicians, each seeking the best care for the patient and each one of a series of checks and balances to ensure that all is in optimal readiness for the patient’s operation. Considering the multitude of drugs the patient may be taking, who knows better than the anesthesiologist the interaction of these drugs with those the patient may be given in the operating room? Not many surgeons or internists have had the training to decipher these interactions. In addition, the anesthesiologist now participates in patient care far beyond the confines of the operating room. He supervises patients in the recovery room and in the intensive care unit when required. He has become a specialist in respiratory and circulatory care. In many institutions, he is a director of the intensive care unit, the inhalational therapy department, and the cardiopulmonary resuscitation t,eam, and often is active in the treatment of pain syndromes. It is evident that at a time when there is need for more personnel to administer anesthetics, the activities of the anesthesiologist make him less available in the operating room even though he is providing better patient care. Rather than allevi607
Editorial
ating the shortage, recent developments may be making it worse. It is this realization that is causing many anesthesiologists to take an appraising look at their daily activities to determine where time and effort can be saved and productivit? increased. A question arises in many of our minds: “Do we need as many anesthesia personnel as we thought we did?” The answer is clearly NO ! The proof is available to any who will survey the activities in most operating room suites. If one accepts 7:00 A.M. to 5:00 P.M.as the normal period of activity in an operating room, the surveyor is likely to find that over a period of a week, the utilization of some operating rooms in the suite will be as low as 10 per cent. Invariably, most rooms will be occupied at 8 o’clock, as the morning progresses utilization diminishes, and by afternoon less than half the rooms are occupied. In many hospitals with which I have been connected or have inspected for various agencies, thp over-all utilization of the operating suite in the time specified has been below 50 per cent. Furthermore, the case load may be very erratic, as exemplified by statistics from one hospital which often has fourteen operating rooms in use at 8:00 A.hl. one day and only four the following. ?tlost surgeons expect to have every operating room staffed and ready for use at any time of the day. *4 hospital with unused operating rooms is therefore going to have personnel equally poorly utilized, and t.he anesthetists are going to be wasting time. The end result is a higher cost of medicine to the patient. Hospitals have the right to have their facilities utilized efficiently. Similarly, anesthesiologists should expect to be fully occupied, which they cannot be if operating rooms are not properly used and if they cannot plan their time beforehand. An operating room is utilized efficiently when it is in use at least 75 per cent of the aforementioned ten hour day. Many reasons have been advanced as to why efficiency is not practical from the surgical point of view. Many specialties suffer from “territorial rights”; they must have an operating room for their own use. In today’s modern hospital practice, this reasoning seems invalid unless a specialty can keep the facility busy within the limits previously described. With most surgeons, early morning priority for operating is a status symbol; consequently, larger operating suites are built to take care of the early schedule with decreasing utilization throughout the day. As each surgeon 608
advances up the staff ladder, he insists more and more upon his prerogative. Nonetheless a surgeon must arrange his day efficiently. He not only has operations to perform, but has rounds to make and office hours to keep. If he is in the academic world, he has teaching and research commitments to keep. By the same token, the anesthesiologist has his responsibilities and a right to the same privilege of arranging his day. Surgeons, anesthesiologists, nurses, and administrators should be able to discuss and plan the activities of an operating suite so that the rooms are appropriately used, yet allow each physician involved to fulfill his own obligations. In such planning, the number of rooms available daily should be diminished progressively until the 75 per cent utilization is achieved. A second means of occupying anesthetic personnel effectively is to so arrange the schedule that patients requiring local anesthesia do not interfere with an orderly progression of those requiring the services of anesthesiologists. Separate operating rooms should be available for outpatients and those for local anesthetics. Lastly, after twenty-five years of observation in operat.ing rooms in this country and abroad, I respectfully submit that the time has come to re-evaluate the time required to prepare and drape patients for operation and to perform the operation once all is in readiness. Is it necessary to scrub each anesthetized patient for ten or more minutes and then envelop him in layer upon layer of sheets and towels? The major preparation can be done before the patient leaves his room. Have we not in america reached the stage where a single layer of an impervious fabric can suffice for draping? It is common for thirty to sixty minutes to pass before the incision is made. Is this not wasteful for all the physicians as well as the other attendants? &lost surgeons prefer not to discuss speed in performing an operation but surely there is good reason to get on with the job with some semblance of urgency. An observer on the British or Continental scene can hardly help but be impressed with the dispatch with which operations are performed there. Good surgical technic should never be sacrificed for speed, but what benefit does either patient or surgeon derive from excessive waste of time? The principal explanation for slowness in operating lies in the failure of disinterested senior surgeons to teach juniors to “move along.” It appears that a renaissance in teaching more rapid surgical technic is long overdue. The American
Journal of Surgery
Editorial
Here then are four major areas in which changes in present attitudes and customs would help alleviate the current and future shortage of anesthetists: more effective utilization of operating rooms, better scheduling, decreased time in preparing and draping patients, and more rapid surgical technic. It is of note that according to data published in 1966 [I], 3.5 per cent of all practicing English physicians (excluding trainees, administrators, and public health officials) were anesthetists. Anesthesia in England is administered solely by physicians. In the United States, 3.1 per cent of all practicing physicians were anesthesiologists, yet they administered less than 50 per cent of all anesthetics. The implicit suggestion is that
Vol.117,May 1969
we are extremely inefficient. As one eminent Rritish surgeon recently said, “It is quite incomprehensible to me that in a country which deservedly prides itself on efficiency, surgeons and anesthetists should continue to tolerate a system in the operating rooms which is responsible for so much loss of time and wasted expenditure.” It is plain to see that we need reorganization in thought and practice. As obvious as it may be, it is not likely to come about easily nor without rancor because the remedy would be unpopular. Reference 1. STWENS, R. Medical Practice In Modern England. New Haven,
1966. Yale University
Press.
609
Most medical manpower surveys reveal a lack of anesthesiologists and anesthetic technicians in this country. An exact definition of the need is obscure but concern has been expressed in many quarters. The output from nurse anesthesia training schools has increased as has the number of trainees in approved residencies in anesthesiology, but little hope has been expressed that the products of these programs can meet future needs. Furthermore, only 70 per cent of the available residency positions are filled. Projection for the future is a continuing inadequate number, even if the present pace of recruitment of physicians into the specialty is doubled or tripled. Perhaps the best indices of the need are apparent to the directors of residency programs. These indices are the number of requests received for anesthesiologists and the number of positions from which each resident completing his t’raining has to choose. He has complete freedom of choice as to geographic location, type of practice, and category of hospital. The beginning incomes are handsome, although not as good as can ultimately be gained by practitioners in many other specialties. Even nurse anesthetists today command salaries ranging as high as $15,000 yearly. Despite the present shortage and bleak future, a discerning observer can hardly overlook the fact that a majority of anesthesiologists and nurse technicians are not fulfilling their potential. Given the opportunity, most could increase and many could double their case loads. Some are satisfied with this state of affairs, but most are not. The directors of many training programs are frustrated over the obvious inefficient use of their staff and the resulting slow progress of many of their trainees. In hospitals with too few st,aff anesthetists, residents often must remain in the operating room constantly to “get the schedule done” to the detriment of their training program;
From the Department of Anesthesia, Northwestern versity Medical School, Chicago, Illinois 60611. Vol. 117, May 1969
Uni-
E. ECKENHOFF,
M.D.,
Chicago,
Illinois
yet’, at the end of the day they may have accomplished relatively little. At one time anesthesiologists were essentially technicians, appearing in the operating room in the morning, anest’hetizing patients without having seen them beforehand and not seeing them again after operation, and leaving the hospital as soon as the operative schedule was completed. This is still the daily rout’ine of the nurse technician and also of some anesthesiologists who choose to keep it this way. Physician technicians are not peculiar to anest,hesia. There are a host of physicians in many specialties whose daily activities have fallen to a technical level. Today’s anesthesiologist is encouraged to be something considerably more than a technician. He carefully examines the patient and his record the day before the operation. His activity should be viewed as that of one of a series of physicians, each seeking the best care for the patient and each one of a series of checks and balances to ensure that all is in optimal readiness for the patient’s operation. Considering the multitude of drugs the patient may be taking, who knows better than the anesthesiologist the interaction of these drugs with those the patient may be given in the operating room? Not many surgeons or internists have had the training to decipher these interactions. In addition, the anesthesiologist now participates in patient care far beyond the confines of the operating room. He supervises patients in the recovery room and in the intensive care unit when required. He has become a specialist in respiratory and circulatory care. In many institutions, he is a director of the intensive care unit, the inhalational therapy department, and the cardiopulmonary resuscitation t,eam, and often is active in the treatment of pain syndromes. It is evident that at a time when there is need for more personnel to administer anesthetics, the activities of the anesthesiologist make him less available in the operating room even though he is providing better patient care. Rather than allevi607
Editorial
ating the shortage, recent developments may be making it worse. It is this realization that is causing many anesthesiologists to take an appraising look at their daily activities to determine where time and effort can be saved and productivit? increased. A question arises in many of our minds: “Do we need as many anesthesia personnel as we thought we did?” The answer is clearly NO ! The proof is available to any who will survey the activities in most operating room suites. If one accepts 7:00 A.M. to 5:00 P.M.as the normal period of activity in an operating room, the surveyor is likely to find that over a period of a week, the utilization of some operating rooms in the suite will be as low as 10 per cent. Invariably, most rooms will be occupied at 8 o’clock, as the morning progresses utilization diminishes, and by afternoon less than half the rooms are occupied. In many hospitals with which I have been connected or have inspected for various agencies, thp over-all utilization of the operating suite in the time specified has been below 50 per cent. Furthermore, the case load may be very erratic, as exemplified by statistics from one hospital which often has fourteen operating rooms in use at 8:00 A.hl. one day and only four the following. ?tlost surgeons expect to have every operating room staffed and ready for use at any time of the day. *4 hospital with unused operating rooms is therefore going to have personnel equally poorly utilized, and t.he anesthetists are going to be wasting time. The end result is a higher cost of medicine to the patient. Hospitals have the right to have their facilities utilized efficiently. Similarly, anesthesiologists should expect to be fully occupied, which they cannot be if operating rooms are not properly used and if they cannot plan their time beforehand. An operating room is utilized efficiently when it is in use at least 75 per cent of the aforementioned ten hour day. Many reasons have been advanced as to why efficiency is not practical from the surgical point of view. Many specialties suffer from “territorial rights”; they must have an operating room for their own use. In today’s modern hospital practice, this reasoning seems invalid unless a specialty can keep the facility busy within the limits previously described. With most surgeons, early morning priority for operating is a status symbol; consequently, larger operating suites are built to take care of the early schedule with decreasing utilization throughout the day. As each surgeon 608
advances up the staff ladder, he insists more and more upon his prerogative. Nonetheless a surgeon must arrange his day efficiently. He not only has operations to perform, but has rounds to make and office hours to keep. If he is in the academic world, he has teaching and research commitments to keep. By the same token, the anesthesiologist has his responsibilities and a right to the same privilege of arranging his day. Surgeons, anesthesiologists, nurses, and administrators should be able to discuss and plan the activities of an operating suite so that the rooms are appropriately used, yet allow each physician involved to fulfill his own obligations. In such planning, the number of rooms available daily should be diminished progressively until the 75 per cent utilization is achieved. A second means of occupying anesthetic personnel effectively is to so arrange the schedule that patients requiring local anesthesia do not interfere with an orderly progression of those requiring the services of anesthesiologists. Separate operating rooms should be available for outpatients and those for local anesthetics. Lastly, after twenty-five years of observation in operat.ing rooms in this country and abroad, I respectfully submit that the time has come to re-evaluate the time required to prepare and drape patients for operation and to perform the operation once all is in readiness. Is it necessary to scrub each anesthetized patient for ten or more minutes and then envelop him in layer upon layer of sheets and towels? The major preparation can be done before the patient leaves his room. Have we not in america reached the stage where a single layer of an impervious fabric can suffice for draping? It is common for thirty to sixty minutes to pass before the incision is made. Is this not wasteful for all the physicians as well as the other attendants? &lost surgeons prefer not to discuss speed in performing an operation but surely there is good reason to get on with the job with some semblance of urgency. An observer on the British or Continental scene can hardly help but be impressed with the dispatch with which operations are performed there. Good surgical technic should never be sacrificed for speed, but what benefit does either patient or surgeon derive from excessive waste of time? The principal explanation for slowness in operating lies in the failure of disinterested senior surgeons to teach juniors to “move along.” It appears that a renaissance in teaching more rapid surgical technic is long overdue. The American
Journal of Surgery
Editorial
Here then are four major areas in which changes in present attitudes and customs would help alleviate the current and future shortage of anesthetists: more effective utilization of operating rooms, better scheduling, decreased time in preparing and draping patients, and more rapid surgical technic. It is of note that according to data published in 1966 [I], 3.5 per cent of all practicing English physicians (excluding trainees, administrators, and public health officials) were anesthetists. Anesthesia in England is administered solely by physicians. In the United States, 3.1 per cent of all practicing physicians were anesthesiologists, yet they administered less than 50 per cent of all anesthetics. The implicit suggestion is that
Vol.117,May 1969
we are extremely inefficient. As one eminent Rritish surgeon recently said, “It is quite incomprehensible to me that in a country which deservedly prides itself on efficiency, surgeons and anesthetists should continue to tolerate a system in the operating rooms which is responsible for so much loss of time and wasted expenditure.” It is plain to see that we need reorganization in thought and practice. As obvious as it may be, it is not likely to come about easily nor without rancor because the remedy would be unpopular. Reference 1. STWENS, R. Medical Practice In Modern England. New Haven,
1966. Yale University
Press.
609