Training the Physician and the Anesthesiologist of the Future

Alex Macario, MD, MBA

August 18, 2010

Introduction

The profession of medicine is changing, especially the future physician workforce (Figure 1). The following factors are fueling this change:

  • Important new rules that govern the residencies that train medical school graduates to become board certified practitioners;

  • Cultural differences between the current generation Y and previous generations; and

  • The evolving gender demographics of medical trainees.

Figure 1. Factors that influence the changing physician workforce.

To successfully recruit and retain the most capable and talented new physicians, it is vital to understand these forces. This article will analyze the status and future of a single medical specialty (anesthesiology) and:

  • Characterize the personal characteristics, attitudes, and preferences of current Generation Y ("millennial") trainees;

  • Describe the evolving gender demographics whereby half of current medical students in the United States are women, the highest percentage in history;

  • Explain how the Accreditation Council of Graduate Medical Education (ACGME) outcomes movement is intended to change residency from an "apprenticeship" model with a fixed, predetermined number of years in training, to a competency-based system, in which progress is determined by reaching specific milestones, such that residencies will vary in length;

  • List the ACGME duty hour regulations and their effect on residency education; and

  • Itemize the ongoing changes in the way that anesthesiologists are trained, which are designed to provide them with state-of-the-art skills in perioperative medicine.

Generation Y: Millennial Trainees

A generation is defined as those individuals born within a 20-year period leading to adulthood. Such a cohort is shaped by common icons, events, and societal forces.[1] The millennial generation is the demographic cohort that followed Generation X (born 1965-1981), and are largely the children of the baby boomers (born 1946-1964) (Figure 2).[2]

Figure 2. Recent generations by year of birth.

Baby boomers often entered medicine as a calling, when society's perception of being a physician was at a high point. Baby boomers are typically described as optimistic, driven, have a "pay your dues" mentality, and have a desire for personal gratification. Millennials are sometimes nicknamed the "trophy kids" (children who get a trophy simply for participating in a youth sport), meant to symbolize a sense of entitlement sometimes perceived by those interacting with millennial individuals (Table 1).

Table 1. Characteristics of the Millennial Generation

Largest generation of young people in the country's history, likely surpassing the aging baby boom generation (78 million)[3]
Economically, they may not be better off than their doting parents, especially after the 2008 worldwide financial crisis
The most ethnically and racially diverse cohort of youth in United States history: 60% (a record low) are white, 19% are Hispanic, 14% black, 4% Asian; and 3% are mixed race or other.[4] They are comfortable with heterogeneity in living arrangement or socioeconomic class
Team-oriented, banding together to socialize rather than pairing off, acting as each other's resources or peer mentors
Civic-minded with a desire to make a positive contribution to society and to the health of the planet[5]
Have been spurred to achievement and display a self-confidence that reflects their being raised in a child-centered world
Comfortable with Web communications, media, and digital technologies (eg, Facebook, YouTube, Google and Wikipedia)
Easier social communication through technology may explain the reputation of the millennial generation for being peer-oriented
Accelerating technologic change may create shorter generations, as young people just a few years apart have different experiences with technology[6]
Increased global exposure through the Web, leading students and residents in record numbers to seek international educational experiences
Many millennials (42% of women and 30% of men) talk to their parents every day and many are still financially dependent on their parents; this has led to a new acronym: KIPPERS (Kids in Parents' Pockets Eroding Retirement Savings).[7] As the skills required for certain jobs become more specialized, many young people return to school for professional degrees with the hope that this additional training will help them land a job. This creates more dependence on others, such as their parents, for financial support.


The values and behaviors of members of each generation can affect the workplace environment. Physicians now at the middle or end of their careers had a high likelihood of being unmarried during their residencies, had a definable body of knowledge to assimilate, and expected to move up in a hierarchical system by "putting their time in." Baby boomers often plan to "work until they die." This ideology and culture can clash with Generation Y, unless both sides attempt to understand the other. Older physicians may equate the desire for work-life balance on the part of the trainee with a lack of professionalism or poor work ethic; sense of humor or manner of dress can also clash. Some employers note that millennials have excessive demands and expectations about work and desire to shape their jobs to fit their lives rather than adapt their lives to their work.

Meeting the Workplace Expectations of Millenials

To attract and recruit the best and brightest millennial graduates, anesthesia employers and residency programs must make communication a priority and develop a more personalized, and supportive work environment with, for example, team building and group activities. At the same time, organizations must acknowledge millennials' commitment to outside activities and family, and other lifestyle needs.

The millennial generation sees incentives other than money as important, uses technology to improve communication, desires flexible working conditions, wishes for opportunities to work remotely, and will accept a lower compensation for working fewer hours. Perks such as sabbatical leaves and other breaks from work will be sought.

An increasing number of physicians graduating from residency programs are foregoing private practice in favor of hospital jobs with steady paychecks and regular hours. Insurers and the business of healthcare are pressuring the viability of solo practice. Large medical groups or hospital systems, by comparison, have more bargaining clout with insurers and can negotiate better payments.[8] Young physicians are increasingly wary and burdened by medical school debts with overall average indebtedness increasing from $25,000 in 1992 to $150,000 in 2009.[9]

Lifestyle also plays a role in the practice locations that millennial physicians choose. The "limitless hours work week" and being on-call around the clock are no longer accepted. Many graduates covet the structure, stability, shift flexibility, and salary-based compensation afforded by the large multispecialty group practices. In fact, more than two-thirds of all practices were physician-owned in 2005, but that share has dropped to below 50%, as more new graduates accept salaries from hospitals and health systems.[10]

Some millennial anesthesiologists may not be interested in partnership tracks, instead preferring a position with no overnight call, part-time hours, or one that allows them to work longer days, but shorter weeks.[11] These physicians are deliberately trading income for predictability in their work lives. This is part of the reason behind the national trend for practices to grow in size, such that more than 15 anesthesia groups now exceed 500 practitioners or work in 3 or more states, and some are even publicly traded companies.[12]

Desire for a controllable lifestyle. A consequence of this generational shift in attitude is reflected in the popularity of specialties that have more "controllable" or limited clinical responsibilities.[13] Controllable lifestyle explains 55% of the variability in which specialties are chosen by medical student, after controlling for income, work hours, and years of training required.[14] Medical students popularized the acronym ROAD to signify specialties generally considered "lifestyle friendly" such as:

  • Radiology;

  • Ophthalmology;

  • Anesthesiology; and

  • Dermatology

Lifestyle specialties are those that offer good pay with minimum work hours, low patient loads, above average working conditions, and typically low on-call time. More recently, the mnemonic has been revised to E-ROAD or ADORE to include emergency medicine.[15] In contrast, specialties such as general surgery, which are not perceived to provide these benefits, have more difficulty filling their open residency training positions.

All specialties in the United States have enough residency positions for all interested American students, with the exception of dermatology, neurosurgery, orthopaedics, otolaryngology, urology, and plastic surgery. These specialties are the most difficult to enter.

Demographic Changes in the Physician Workforce

Although an in-depth analysis of how many trainees are needed to meet the anticipated demand for physicians in the United states is beyond the scope of this article, several observations are noteworthy. In 2006-2007, 49% of graduating medical students in the United States were women, the largest proportion ever, and up from 27% in 1983.[16] The percentage of women entering anesthesiology in 2009 was 40%, up from 28% in 2000.[17]

This "feminization" of medicine is also occurring globally.[18-20] In the United Kingdom, 57% of medical students are women. By 2017, most National Health Service physicians will be women.[21] In Canada, female medical students currently outnumber their male counterparts; women who are physicians work an average of 48 hours per week, compared with 54 hours by men.[22] According to Weizblit and associates, if these gender-specific work patterns persist, an overall decline in physician work productivity in Canada will follow.[22]

The trend toward fewer overall hours worked will increase because millennial graduates, regardless of gender, intend to work fewer hours.[23] A2007 United States survey found that 24% of women physicians younger than 50 years of age workpart-time.[24] The average work hours per week for physicians in the United States has decreased from 55 in 1996-1998 to 51 in 2006-2008.[25]

Another demographic issue is that many current physicians in training are older, as the traditional life stages (going to college, leaving home, getting married, having children, retiring) are no longer directly related to chronological age.[26] For example, mothers can have their first child in any of several decades, from their 20s through their 40s. Stay-at-home dads are no longer uncommon.[27]

This switch from chronological age to life stage is also observed among current residency applicants. For example, for a resident to have children at home was previously infrequent but is now common. Also, many residency applicants have switched professions and gone back to school to start a second career in medicine. These "non-traditional" students bring maturity, ease at the bedside, and perspective from their life experiences.

Future of the Anesthesia Workforce

Whereas the optimal number of anesthesiologist trainees is unknown, demand for anesthesia services has risen steadily since the 1990s, opening up the possibility for future personnel shortages. Recent research by RAND Health indicates a projected shortage of anesthesiologists in the United States by 2020.[28]

ACGME Outcomes Movement

Clinical competency. It is often surprising to the public at large that the various medical and surgical specialties do not have uniform, well-defined, and validated sets of criteria with which measure the overall competency of residents when they finish their residency programs.

Many believe that the traditional "apprenticeship" model of residency, developed a century ago in an era of primarily office-based private practitioners, is outdated and in need of modernization. Questions arise about substandard physicians being allowed to graduate, especially given that evaluation methods used in residencies may not accurately assess performance. Because the funding of resident education relies on public monies, a mandate now exists to make accountable to public scrutiny the competence of physicians when they finish training.

Concerns have been expressed about whether these residency graduates are properly educated for today's practice environment and demands, and about aspects of physician competence that have not been traditionally measured, such as self-assessment, practice assessment, and lifelong learning and improvement.[29] Patients and families often focus on a physician's interpersonal skills, communication, and professionalism, skills that are not traditionally taught in a formal manner.

The mission of the ACGME is to improve healthcare by assessing and advancing the quality of resident physicians' education through accreditation. The ACGME's method of proving to the public that physicians are competent took form in 1996 with a long-term initiative known as the Outcomes Project. Educational outcome data were deemed necessary to confirm that newly graduated physicians were properly prepared and competent to practice. Although some skills can be measured objectively, reliable assessment is challenging for areas such as professionalism and communication.[30]

ACGME identified 6 general core competencies (acronym SKIPPP) defining the desired outcome of training (Table 2).

Table 2. The 6 ACGME Competencies: SKIPPP

S Systems-based practice
Acknowledges that good patient care now requires more than the dedicated work of an individual physician, but a team of professionals working inside a large, complex health system
K Knowledge
I Interpersonal communication skills
P Professionalism
P Practice-based learning and improvement
P Patient care


Although no scientific data document that competency-based education will result in better physicians, the residencies of the next decade will be quite different from the residencies that baby boomers completed.

Competency paradigm implemented in other countries. The Royal College of Physicians and Surgeons of Canada championed the CanMEDS (Canadian Medical Education Directives for Specialists) framework for medical education to improve patient care.[31] The framework has 7 core roles for the 21st century physician: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional.

In the United Kingdom, the General Medical Council is promoting "Tomorrow's Doctors" as a competency-based framework for medical school education.[32]

ACGME Duty Hour Regulations

The Federal Aviation Administration does not permit pilots to work more than 16 hours, and mandates an 8-hour rest break. Some have called for a similar limit on shift duration for the practicing anesthesiologist. This would reduce fatigue and perhaps increase safety, but ideally also increase the long-term wellness of the physician.[33]

A Web-based survey of 2737 interns assessed the effect of 24-hour "extended duration" shifts on the number of significant medical errors reported by the interns. They found that compared with months when no 24-hour shifts were worked, when interns worked 1-4 of these 24-hour shifts in a month, they were 3.5 times more likely to make at least 1 fatigue-related significant medical error. When they worked 5 or more of these extended-duration shifts in a single month, interns were 7.5 times more likely to make such an error.[34] The same survey found that extended shifts increased the risk for motor vehicle crashes.[35]

Since 2003, the ACGME has instituted limits on resident work hours including all hospital or clinic time and including on-site learning activities (Table 3).

Table 3. ACGME Duty Hour Rules

Limited to 80 hours per week, averaged over a 4-week period
One day in 7 must be fully free from all responsibilities, averaged over 4 weeks
10-hour break between all shifts
In-house call no more than every third night, averaged over 4 weeks.
Continuous on-site duty must not exceed 24 hours; residents may remain on duty for up to 6 additional hours for didactics, transfer care of patients, outpatient clinics, and to maintain continuity of care
No new patients after 24 hours of continuous duty
Residents taking at-home call must be provided with 1 day in 7 completely free, averaged over 4 weeks


The strength of this movement is reflected by the fact that in 2008, based on 2 studies,[36,37] the Institute of Medicine issued a report recommending even more restrictive limits on resident work hours than current ACGME rules.[38]

Prominent residency programs have been put on probation as a result of ACGME duty hour violations.[39] If probation is not resolved and a residency loses ACGME accreditation, then the program foregoes eligibility for Medicare Graduate Medical Education funding and residents are not eligible to sit for board certification exams.

These duty hour restrictions have led to concern that new young physicians will have a shift-work mentality, rely unnecessarily on handoffs, and not take full ownership for the care of their patients.[40]

Dr. Nasca, ACGME's Chief Executive Officer highlights some related points[41]:

  • The fact that no effect of the 2003 resident duty hour rules on patient outcomes has been demonstrated is understandable because of the redundant systems of patient safety in a hospital;

  • The reduction in the direct responsibility and authority for patient care by residents because of new resident duty hour standards may have the unintended consequence of removing the resident from the previously held "pivotal role" in the care of patients;

  • Residency training in the United States has more responsibility for delivery of a proficient practitioner (able to handle the unsupervised practice of medicine in a variety of settings) at completion of residency than it does in many other countries. For example, in the United Kingdom, "graduates" remain within the teaching hospital, under faculty supervision, for several more years;

  • Residents are sleeping about the same number of hours each night as they were before the new duty hour regulations; and

  • Although most believe that physicians must not be governed by the clock, when a patient needs assistance, residents may face a conflict of committing a duty hours violation when a patient needs their continued assistance.

Changes to Anesthesia Residency Requirements

In 2008, the Anesthesiology Residency Review Committee of ACGME instituted important changes to the rules governing anesthesia resident education. The spirit of these changes was to develop a better perioperative physician, with new requirements in preoperative medicine, intensive care, chronic and acute pain, and post-anesthesia care (Table 4). This, however, has meant less time in the operating room (OR) for trainees, which is of some concern to educators as the complexity of OR cases increases.

Table 4. Required Rotations for Anesthesia Residents[42]

Rotation Number of Months
Pediatrics 2
Intensive care unit 4
Obstetrics 2
Neuroanesthesia 2
Acute pain 1
Chronic pain 1
Regional/nerve blocks 1
Post-anesthesia care unit 0.5
Preoperative medicine 1
Cardiac 2


The fellowship movement. As subspecialization rises in all areas of medicine, the anesthesiologist who seeks employment in the future is more likely to have completed a fellowship that requires a fifth training year after medical school. At the Stanford anesthesia residency, two-thirds of graduates are entering fellowships, the largest proportion ever.

The increasing number of candidates seeking additional fellowship training could be evidence that trainees themselves desire more experience to practice safely and independently. Another explanation for the demand for fellowship training is that housestaff want more specialized knowledge to fully provide perioperative patient care. Residents may also perceive extra fellowship credentials to be a method for gaining a competitive edge over existing practitioners and nonphysician anesthesia providers.

The fellowships that are recognized by ACGME (which follow the same duty hour and competency rules as residencies) are:

  • Pain medicine;

  • Critical care medicine;

  • Cardiothoracic anesthesia; and

  • Pediatric anesthesia.

If more anesthesia residents (the total number is approximately 1500 graduates per year) plan to do fellowships, and the number of fellowship slots is fixed (at approximately 600-700 for the 4 ACGME accredited fellowships), what other fellowships are available? The list of non-ACGME fellowships includes:

  • Obstetric anesthesia

  • Patient safety & crisis management

  • Clinical research

  • Laboratory research

  • Management of perioperative services

  • Neuroanesthesia

  • Difficult airway/ear-nose-throat

  • Regional anesthesia

  • Liver transplantation

  • Pediatric pain management

  • Informatics

What Will the Anesthesia Residency Look Like in 20 Years?

The anesthesiologist of the future will be trained to seek, and take advantage of a wide array of opportunities from sedation for out of OR cases to palliative care for children to institutional leadership roles (eg, direct OR suites, pain consultation services or intensive care units) as well as positions in preoperative evaluation centers (in and out of hospital optimization services).[43]

Some predictions for residency training in the future include the following possibilities:

  • Medicare will no longer pay for residents, so the hospital or the anesthesia department will have to fund their salaries;

  • Medicare will start linking reimbursement to promises by trainees to enter certain subspecialties that have inadequate numbers of providers, or to promises by resident to practice for specified periods of time in underserved areas;

  • Residents will pay tuition for training opportunities to become specialists, and they will customize their training by selectively choosing from a menu of cases and rotations. Residents will be more like medical students in this model;

  • Anesthesia residency will not last 4 years, but be of variable length on the basis of predetermined milestones. The core training will continue because any supervision requires in depth OR anesthesia expertise, but the advanced training could be in a variety of perioperative areas. If the resident is really proficient and shows the required skills, attitudes, and knowledge, he or she could finish in 3.5 years for example, and if not, it could take more than 4 years to meet the requirements[44];

  • More customization of the curriculum to meet each trainee's career goal will be possible. For example, each resident might choose either a critical care medicine or pain medicine track for the final year of core residency training.[45] This way, as many as 24 months of a 5 year training period could be focused on the subspecialty;

  • Clinical subspecialty fellowships will have added a second research-intensive year[46];

  • Residencies will offer rotations in developing countries to respond to interest in global health[47];

  • Faculty will be expert in competency-based education. Portfolios, videos of actual patient encounters, case logs and reflective essays will be routine; and

  • Sophisticated assessments of competency will be readily available. Team learning and team experiences in a high fidelity simulation facilities will be widespread.

Conclusion

Medical training and practice exist in a dynamic marketplace with supply and demand modulated by major trends, such as new technologies and treatments, national healthcare reform, reimbursement changes, and the general state of the economy. In addition to providing outstanding patient care, tomorrow's anesthesiologist will be fully trained to critically analyze literature as a natural part of their best practice routine, as outlined by the practice-based learning and improvement ACGME competency, and will be expert in managing the complex healthcare systems to ensure that their patients have optimal care as outlined by the competency for systems-based practice.

Dramatic changes in the up-and-coming physician workforce will affect all of medicine, including anesthesiology. These changes include the generational characteristics of the millennial generation, evolving gender demographics whereby half of current medical students in the United States are women, the movement led by ACGME to satisfy the public's desire to have demonstrated competency of new physicians, the application of duty hour regulations, and other changes to residency education intended to instill state-of-the-art perioperative competencies.

The Anesthesiologist of the Future

  • Will be trained to seek and take advantage of opportunities to lead and help the hospital and medical group deliver high quality, cost-efficient care;

  • Anesthesia groups strategizing for the future must anticipate clinical and business opportunities; and

  • The key to incorporating the millennial anesthesiologist is to match the needs of the clinical practice with the talents and motivations of the available workforce. A more family- and life-friendly work environment will attract the best and brightest of the millennial generation.

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