Society of Cardiovascular Anesthesiologists

President's Message

The Challenges Ahead

This being my last message to you, I would like to focus on the future of our subspecialty and some of the challenges that it, and SCA, will face. The manpower pendulum has swung. Whereas a few years ago our graduating residents were unable to find staff positions, anesthesia practices now have great difficulty finding graduating residents. If you missed Mark Lema's editorial "In case you haven't heard … there are no available anesthesia providers" in the February 2001 ASA Newsletter, I strongly suggest that you read it and forward it to administrators at your institutions. The extreme swings in practice opportunities that our specialty has experienced in the last decade undoubtedly influence how residents approach career choices and subspecialty training options.

From 1993 to 1996, the size of CA-3 graduating classes hovered around 1,700 residents. The number of residents electing to obtain at least 12 months of cardiothoracic anesthesia training was 55 in 1993, 65 in 1994, 70 in 1995 and 78 in 1996. These numbers represented approximately 4 % of the graduating classes. Whether such interest was sufficient to meet the community's needs for cardiothoracic anesthesiologists is difficult to gauge. I used the ratio of cardiothoracic anesthesia fellows-to-cardiac surgical discharges as a possible marker of such a need. My analysis demonstrates a relatively constant ratio of approximately 1 trainee/6,000 cardiac surgical discharges for the years 1993-96. There are no data, however, to indicate whether that ratio reflects an adequate production of cardiothoracic anesthesia subspecialists for the needs of the community.

After 1996, the size of our CA-3 graduating classes decreased dramatically and a nadir of 919 graduates was observed in July 2000. The decreased production of anesthesia graduates is most likely one of the main reasons for the difficulties that anesthesia practices currently experience in the recruitment of new staff. This acute shortage, however, represents a very recent reversal of the general perception that few anesthesia positions existed and that the completion of an anesthesia residency did not necessarily lead to a guaranteed staff position. The precise timing of this radical reversal is not totally evident, but occurred at some time between 1996 and 2000. Over the same time period, the percentage of CA-3 graduates electing to spend another year of training in cardiothoracic anesthesia doubled from 4 % to more than 8 %. While the increased interest in cardiothoracic anesthesia was certainly welcome, one can wonder whether it represented a transient phenomenon related to job market conditions or a true increased interest in the subspecialty. Irrespective of these shifts in anesthesia manpower, the growth of cardiac surgery continued unabated. As a result, the ratio of cardiothoracic anesthesia trainee-to-cardiac surgical discharges had decreased to 1/8,000 by 2000, despite an increased production of cardiothoracic anesthesia subspecialists to nearly 100 per year.

What will the future bring? It is obviously difficult to predict the level of interest in cardiothoracic anesthesia amongst the current anesthesia residents or the rate of growth in cardiac surgery. Nonetheless, one can look at recent history and extrapolate possible outcomes. Historically, 4 % of graduating anesthesia residents chose cardiothoracic anesthesiology as a subspecialty. If one applies this historic percentage to the class that will complete core anesthesia training in 2003, 51 residents will select cardiothoracic anesthesiology in 2003 and graduate from fellowships in 2004. Similarly, if we assume that the historic growth rate in cardiac surgery will remain constant, cardiac surgical discharges will increase from the current 700,000 to 930,000 in 2004. If both of these assumptions are correct, the ratio of cardiothoracic anesthesia trainee-to-cardiac discharges will fall to 1/18,000. This would represent a 66 % reduction in the cardiothoracic anesthesia trainee-to-cardiac surgical discharges ratio when compared to the early nineties.

We don't know the optimal ratio of cardiothoracic anesthesia trainee-to-cardiac surgical discharges. The spread between 1/6,000 and 1/18,000 is, however, huge and must have an impact on the care of the cardiac surgical patient. It may be that we produced far too many cardiothoracic anesthesiologists in 1993 and that, as a result, all cardiac surgical patients had access to a cardiothoracic anesthesiologist for their care. I personally doubt that such was the case. In 2004, when the ratio will be 1/18,000 it is almost certain that only the occasional cardiac surgical patient will benefit from the expertise of a cardiothoracic anesthesia subspecialist. In addition, with such a low production ratio, it is not clear as to how many cardiothoracic anesthesiologists will be available to teach residents and fellows and conduct research, two activities that are crucial to the future of the subspecialty.

What can SCA do? First, we should get a handle on manpower data. While it is a difficult task, we should at least begin the process that may result in a better understanding of the current and future needs for cardiothoracic anesthesiologists. Secondly, we should explore how anesthesia residents can be convinced to envision cardiothoracic anesthesiology as a stimulating and rewarding career choice. Graduating residents have numerous career options and we must ensure that cardiothoracic anesthesiology is at least given a fighting chance. Thirdly, we must ensure that the anesthesia residents who select cardiothoracic anesthesiology obtain appropriate training in an environment that is conducive to academic fulfillment. Approval of subspecialty accreditation by ACGME is critical. Finally, we must better understand how current practitioners can be helped in maintaining their enthusiasm and dedication for cardiothoracic anesthesiology. Education is what SCA has done well in the past, but advocacy is what may be needed in the future.

As indicated in my opening sentence, this is my last presidential message and, therefore, many of the challenges that I outlined will need to be tackled by my successors. Fortunately, SCA is blessed with the ability to attract wonderful individuals into leadership positions. I am fully confident that the new SCA leadership will approach these challenges with determination and great skill. As for my own involvement, I will be delighted to participate and contribute whenever asked. It has been a great honor and privilege to lead this wonderful organization. I wish to thank all, including officers and directors, committee chairs and members, individual SCA members, and the Ruggles Service Corporation for making this an amazingly rewarding and fun assignment.

Comments or suggestions on this topic can be communicated to me at sca@societyhq.com or at dthys@slrhc.org. After editorial review by the Newsletter Committee, they will be published.

Daniel M. Thys, M.D., F.A.C.C.
President, SCA