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Workforce and Finances of the United States Anesthesiology Training Programs

2009–2010

Kheterpal, Sachin, MD, MBA; Tremper, Kevin K., PhD, MD; Shanks, Amy, MS; Morris, Michelle, MS

doi: 10.1213/ANE.0b013e3182135a3a
Economics, Education, and Policy: Brief Report
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Financial and workforce surveys were sent to 121 and 124 United States Anesthesiology training programs in 2009 and 2010, respectively. Seventy-two respondents (60%) and 81 respondents (65%) demonstrated median institutional support per faculty of $120,000 and $111,000; open faculty positions of 4% and 4.8%. Faculty billed an average of 11,050 units/year and collected $35.00/unit. In 2010, 56% of departments had installed anesthesia information management systems and 14% have signed a contract for an anesthesia information management system.

Published ahead of print May 4, 2011

From the Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan.

Supported by departmental sources only.

Address correspondence and reprint requests to Sachin Kheterpal, MD, MBA, Department of Anesthesiology, University of Michigan Medical School, 1500 E. Medical Center Dr., UH 1H247, Box 0048, Ann Arbor, MI 48109. Address e-mail to sachinkh@med.umich.edu.

Accepted January 28, 2011

Published ahead of print May 4, 2011

A decrease in anesthesiology residency program applications in the mid-1990s led to a decrease in the number of graduates starting in the year 2000.15 Since 1999, an annual survey has been distributed to the chairpersons of the United States (U.S.) academic anesthesiology training departments to quantify the faculty workforce issues and financial status of their programs.27 Although the percentage of open faculty positions has fluctuated from that time to the current day, most departments have continued to report open positions. We present the results of the 2009 and 2010 surveys, which included new data elements regarding faculty variable compensation, intensive care unit (ICU) staffing, certified registered nurse anesthetist (CRNA) supervision, and the current status of anesthesia information management system (AIMS) implementation.

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METHODS

For the past 10 years, an electronic mail survey has been sent to the chairs of the U.S. anesthesiology training programs. This survey has been presented in detail in previous publications.27 The 2009 and 2010 surveys also included 4 additional topics (Appendix 1). First, it inquired whether the department provided faculty variable compensation for evening work and, if so, what time it started and the hourly rate disbursed. Second, the 2009 survey requested the number of ICUs in which the department's faculty were involved and the structure of the anesthesiology team's responsibility: (A) an open unit where the ICU team did not write orders; (B) a “hybrid unit” where the ICU team provided consultation services; (C) a “hybrid unit” where the ICU team writes patient orders; and (D) a closed unit where the ICU team has total patient responsibility. Third, the survey requested departments with CRNA supervision to estimate the percent of the time the following supervision ratios were used: 1:1, 1:2, 1:3, or 1:4. Finally, the 2010 survey asked whether the department has an AIMS installed and, if not, have they signed a contract to have one installed. The electronic mail surveys were sent starting in the third week of August and reminder surveys were sent to nonresponders every 2 weeks for the next 10 weeks.

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RESULTS

The surveys were distributed to 121 and 124 chairs, respectively, for 2009 and 2010, who are members of the Society of Academic Anesthesiology Associations (SAAA). The response rate was 60% (72 of 121) and 65% (81 of 124). The descriptive statistics are presented in Tables 1 to 6.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

Table 6

Table 6

The following data are for the 2010 survey. The average academic anesthesiology department has 58 faculty, 8 fellows, 43 residents (14/year), 10 interns (80% of departments offer internships), and 39 CRNAs (96% of the departments have CRNAs). In the 83% of departments that had open faculty positions in 2010, there was an average of 3.3 open positions. Incorporating the sites that do not have open positions, this translates to national 4.8% open rate among responding institutions. Similar to 2008, the most common “subspecialty” need was generalist, followed by pediatric anesthesiology, critical care, cardiac, and pain management, respectively (Table 7). The median amount of academic time has remained steady at 15%. There were 3.4 open CRNA positions per department, translating to a national average open percentage of 8% (Table 2). Total revenue per faculty full time equivalent (FTE) averaged $643,000 (Table 3). A faculty FTE is defined as an anesthesiologist employed at a 100% appointment. This total revenue was composed of clinical revenue ($440,000/ faculty FTE), research revenue ($23,000/faculty FTE), and institutional support ($165,000/faculty FTE) (Table 3). When the portion of institutional support used for CRNA salaries is removed, the institutional support is $130,000/faculty FTE. The departments billed an average of 11,050 units per faculty FTE in 2010 and collected $35.50 per unit billed (Table 5). The average number of clinical sites staffed in 2010 is 57 (Table 6).

Table 7

Table 7

Sixty-four percent (52 of 81 responders) of academic departments pay late pay, which started at median 5:00 PM (25th percentile of 4:00 PM and 75th percentile of 5:00 PM) and paid at a median rate of $150/hour (25th percentile of $125 and 75th percentile of $163). For 2009, the departments managed an average of 2.2 ICUs. They reported a mix of ICU models: 8% used an open model, 52% a hybrid consultative model, 55% a hybrid order writing model, and 23% a closed model (because a given institution may use >1 model, the sum of the responses is >100%). In terms of CRNA supervision, a 1:2 ratio was the most prevalent, being used on average 70% of the time (Table 8). As of the Fall of 2010, 56% of departments (43 of 77) had an AIMS installed and another 14% had signed a contract to install an AIMS.

Table 8

Table 8

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DISCUSSION

The observed open faculty position percentage (4.0%–4.8%) compares well with the data received from the yearly Society of Academic Anesthesiology Associations' Salary Survey distributed by the University of Florida, which demonstrated 3.9% open positions in 2010.a The number of open faculty positions has decreased from the year 2000 and seems to have stabilized at approximately 4% to 5% (Table 2).1

Although the number of departments with CRNAs and the number of CRNAs in each department has increased over the past decade, the percentage of open CRNA positions (8%) may be decreasing.1,4 Faculty support per FTE (with CRNA support removed) seems to have leveled off at approximately $130,000/faculty FTE and $110,000/faculty FTE, mean and median, respectively. This high level of departmental support is in the broader context of increasing academic salaries, with the 50th percentile for an anesthesiology assistant professor increasing to $305,250/year.b In addition to increasing salaries, our data reveal an increase in average dollars collected per unit by $1 between 2008 and 2010. The revised Medicare Teaching Rule, which allows 100% reimbursement for supervising 2 residents starting in January 2010, may be partially responsible for this increase in collections.8 However, Medicare is not the majority payer at most facilities.2 The current data demonstrate that the majority of departments pay additional compensation starting at a median of 5:00 PM.

The American Board of Anesthesiology requires 4 months of critical care training for each resident, and this training must occur in an ICU environment where anesthesiology faculty perform a substantial role.9 It seems that anesthesiology departments have a significant role in their institution's ICU staffing despite a national shortage of intensivists and chronically unfilled fellowship programs.10 The average department covers >2 units and the predominant model is to manage those patients with an order-writing team or a consultative team.

In 2007, an e-mail survey was sent to the U.S. academic anesthesiology chairs regarding their status of AIMS implementation and planned implementations.11 This survey noted that approximately 28% of departments (12 of the 72 respondents) had an AIMS installed, 11 had selected an AIMS but had not yet installed it, and another 18 were planning to purchase an AIMS within the next 2 years. It seems that progress has been made with respect to adoption of the AIMS with >70% of academic departments having either currently installed an AIMS or having signed a contract to do so.

Our data suffer from the potential errors associated with the survey methodology itself and have been previously described.37 A skewed response population or errors in the respondents' understanding of the survey questions are the 2 most common errors that may affect accuracy.

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DISCLOSURES

Name: Sachin Kheterpal, MD, MBA.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Sachin Kheterpal has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Kevin K. Tremper, PhD, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Kevin K. Tremper has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Amy Shanks, MS.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Amy Shanks has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Michelle Morris, MS.

Contribution: This author helped conduct the study and analyze the data.

Attestation: Michelle Morris has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

a 2010 SAAA Salary Survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, FL.
Cited Here...

b 2010 SAAA Salary Survey, personal communication with Rebecca Lovely, University of Florida, Gainesville, FL.
Cited Here...

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REFERENCES

1. Tremper KK, Reves JG, Barker SJ, Saubermann A, Gelman S. Financial environment of academic anesthesia. In: Lake CL, Johnson JO, eds. Advances in Anesthesia. Carlsbad, CA: Mosby, 2001:1–35
2. Tremper KK, Barker SJ, Gelman S, Reves JG, Saubermann AJ, Shanks AM, Greenfield ML, Anderson ST. A demographic, service, and financial survey of anesthesia training programs in the United States. Anesth Analg 2003;96:1432–46
3. Tremper KK, Shanks A, Sliwinski M, Barker SJ, Hines R, Tait AR. Faculty and finances of United States anesthesiology training programs: 2002–2003. Anesth Analg 2004;99:1185–92
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
5. Tremper KK, Shanks A, Morris M. Five-year follow-up on the work force and finances of United States anesthesiology training programs: 2000 to 2005. Anesth Analg 2007;104:863–8
6. Kheterpal S, Tremper K, Shanks A, Morris M. Seventh and eighth year follow-up on workforce and finances of the United States anesthesiology training programs: 2007 and 2008. Anesth Analg 2009;109:897–9
7. Kheterpal S, Tremper KK, Shanks A, Morris M. Six-year follow-up on work force and finances of the United States anesthesiology training programs: 2000 to 2006. Anesth Analg 2009;108:263–72
8. Medicare Teaching Rule. Text of H.R. 6331: Medicare Improvements for Patients and Providers Act of 2008. Available at: http://www.govtrack.us/congress/legislation.xpd. Accessed March 4, 2011
9. The American Board of Anesthesiology Certification Requirements Booklet. Raleigh, NC: The American Board of Anesthesiology, 2010:11. Available at http://www.theaba.org/Home/anesthesiology_initial_certification. Accessed March 4, 2011
10. Krell K. Critical care workforce. Crit Care Med 2008;36:1350–3
11. Halbeis E, Epstein RH, Macario A, Pearl RG, Grunwald Z. Adoption of anesthesia information management systems by academic departments in the United States. Anesth Analg 2008;107:1323–9

This is a follow-up survey to the Faculty and Finance Survey from past years. (This is not the SAAC Salary Survey from the University of Florida, Gainesville.) This survey refers only to your primary teaching Hospital or Hospitals for which you are fiscally responsible for the Department's faculty, income, and expenses. The results will be presented this fall at the annual SAAA meeting and only the responders will have access to results via e-mail from Amy Shanks at amysha@umich.edu. If you have any questions, please e-mail ktremper@umich.edu or amysha@umich.edu.

Please reply by following the directions below:

  1. Select “Reply” to this e-mail message.
  2. Scroll down and answer the questions.
  3. Send/Return this e-mail to me.
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APPENDIX I: 2009 FOLLOW-UP SOCIETY OF ACADEMIC ANESTHESIOLOGY ASSOCIATIONS' SURVEY

I. Staffing

How many residents do you have in?

  • CA-0 (Internship) ——————
  • CA-1 ——————
  • CA-2 ——————
  • CA-3 ——————
  • (ACGME Approved or Not) CA-4 (Fellowships) ——————

How many faculty anesthesiologists (FTE) do you have? ——————

(A faculty anesthesiologist (FTE) who is employed full-time is one FTE regardless of his/her percent of nonclinical time.)

How many total open faculty positions do you have? ——————#

If you have any open faculty positions, which subspecialties do you want to fill?

  • Generalist ——————#
  • Cardiac ——————#
  • Peds ——————#
  • ICU ——————#
  • OB ——————#
  • Neuro ——————#
  • Regional ——————#
  • Ambulatory ——————#
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CRNA

How many total CRNAs do you have in your hospital? (Total CRNAs paid for by all sources) ——————#

How many open CRNA positions do you have? ——————#

How many CRNAs are paid for by your Department? ——————#

How many CRNAs are paid for by your Hospital? ——————#

How many CRNAs are paid for by Other Sources? ——————#

Question: Could you please answer your best estimate of the faculty supervision ratios at your institution? (in %s adding up to 100%)

  • Faculty supervising 1 CRNA: ————
  • Faculty supervising 2 CRNAs: ————%
  • Faculty supervising 3 CRNAs: ————%
  • Faculty supervising 4 CRNAs: ————%
  • Faculty supervising >4 CRNAs: ————%
  • 100%
  • For example, at the University of Michigan:
  • Faculty supervising 1 CRNA: —0——
  • Faculty supervising 2 CRNAs: —70——%
  • Faculty supervising 3 CRNAs: —20——%
  • Faculty supervising 4 CRNAs: —10——%
  • Faculty supervising >4 CRNAs: —0——%
  • 100%
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II. Department Finance (for Fiscal Year Ending 6/30/09)

A. Revenue: Total Department Revenue (1 + 2 + 3 + 4 from below) $——————

What was your department's:

  1. Clinical Revenue? $——————
  2. Research Revenue? (direct dollars only) $——————
  3. Total Institutional Support? $—————— of this number,
    • How much is from the Hospital? $——————
    • How much is from the Med School? $——————
    • How much is from Other sources? $——————
  4. Other income (gifts, royalties, interest, etc.) $——————

Does your institutional support dollars include funds to support CRNA salaries? () Yes () No

If yes, how much? $——————

B. Expenses: Total Department Expenses? $——————

C. Profit/Loss: Department's Profit or Loss (A − B = C) $—————— (place a minus sign in front of a loss)

Department's profit or loss for the fiscal year ending 6/30/09. This profit or loss is after all revenue and all expenses (including research, year-end bonuses, institutional expenses, etc.) are accounted for. Note: Your total revenue minus your expenses should equal your profit or loss. If not, please explain below: ——————————————————————————

Special Unit/Clinic Revenue:

  • What was your Pain Clinic professional fee revenue? $——————
  • What was your Acute Pain professional fee revenue? $——————
  • What was your Critical Care professional fee revenue? $——————
  • What was you Preop Clinic professional fee revenue? $——————

How many total anesthetic units did you bill last year? ——————

(e.g., the University of Michigan billed 835,105 units in Fiscal Year 2007)

What was the average number of time units/case? #——————

How many cases did you conduct/bill last year? #——————

(University of Michigan billed about 58,000 in 2008)

What % of collections do you allocate to CRNAs, when a physician and a CRNA are participating in the care? ——————%

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III. Faculty Compensation

Do you pay additional compensation to faculty solely due to their subspeciality training? () Yes () No

  • If yes, how much additional pay?
  • Cardiac $——————/year
  • ICU $——————/year
  • Peds $——————/year
  • Pain $——————/year
  • OB $——————/year
  • Neuro $——————/year
  • Other $——————/year

Do you pay faculty hourly for late coverage? () Yes () No

If yes, how much per hour? $——————/hour

If yes, what time of day do you start the late pay? —————— PM

If you have some other type of late payment (i.e., not hourly), please explain: ——————————————————————————

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IV. Faculty Nonclinical Time

What is the average amount of nonclinical (academic) time per faculty, not counting the day after in-hospital call? (1 day per week = 20%) ——————% (for this calculation, if your faculty start late on the day they are on in-hospital call, count this as an academic day)

If your faculty start late on the day of in-hospital call, do you ordinarily count this day as an academic day?

Yes () No ()

How many vacation days do your faculty receive? (5 days = 1 week) —————— days/year

How many meeting days do your faculty receive? (5 days = 1 week) —————— days/year

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V. Unit Value Charge

What is your gross unit value charge for anesthesia? $——————/unit

(University of Michigan charges $95 per Anesthesiologist professional fee Unit)

What is the average unit dollar amount you collected $——————/unit

(e.g., the University “A” charges $100/unit, but collects $40/unit on average per Anesthesiologist professional fee Unit: $40 would be the correct response)

What unit value do you receive from Medicaid? $——————/unit

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VI. Clinical Coverage

How many ORs does your department cover each day? ——————/day

  • How many non-OR/offsite locations does your department cover each day? ——————/day
  • (e.g., MRI, CT, Angio, EP, Cardiology)
  • How many OB deliveries (with anesthesia involvement) does your department have each year? ——————/year
  • How many faculty do you have on each of these services per day? ——————
  • (At Michigan, we have 1 on OB, 2.5 on ICU, and 3 in the pain clinic. If it is zero, please note that)
  • OB ——————/day
  • ICU ——————/day
  • Acute Pain ——————/day
  • Pain Clinic ——————/day
  • Preop Clinic ——————/day
  • Other (specify) ——————/day

ICU Management Type: Could you select the type of ICU management from the 4 types listed below for each of the ICUs in which your faculty attend and residents train?

  • Types:
  • A. Open ICU: Admitting service remains primary service and writes orders on their patients. No formal intensive care physician input or only ICU physician consultation with no order writing by ICU team.
  • B. Open “Hybrid” ICU: Admitting service remains primary service and writes orders on their patients. Intensive care physician/service consults and can write orders as well.
  • C. Closed “Hybrid” ICU: Intensive care physician/ service becomes primary service and cares for patient primarily and writes all orders (“single order ting service”). Admitting service continues to actively round on admitted ICU patients with ICU team and routes orders through ICU team via a collaborative team effort.
  • D. Fully Closed ICU: Intensive care physician/service takes over patient care and writes all orders with minimal input from primary service (common in medical ICUs).
  • ICU #1 management type = ———
  • ICU #2 management type = ———
  • ICU #3 management type = ———
  • ICU #4 management type = ———
  • Add more ICUs if needed

2010 follow-up survey asked an additional AIMS question:

  • Do you have an AIMS installed? Yes () No ()
  • If no, have you signed a contract for an AIMS? Yes () No ()
  • Thank you for taking the time to complete this e-mail.
  • Kevin K. Tremper, PhD, MD
  • Robert B. Sweet, Professor and Chair
  • Department of Anesthesiology
  • University of Michigan
  • 1500 E. Medical Center Dr.
  • Ann Arbor, MI 48109-0048
  • (734)936-4235
  • ktremper@umich.edu
© 2011 International Anesthesia Research Society