In the past few years, however, market forces have put th
In the past few years, however, market forces have put the squeeze on anesthesia, starting with a moderation in surgery volume. Widely quoted studies by Rand Corp., a Santa Monica, Calif., research group, have suggested that at least one-third of some common procedures _ such as hysterectomies, insertion of middle-ear tubes and angioplasties _ are either inappropriate or of uncertain benefit.
HMOs and other managed-care plans have responded by nudging down surgery and hospitalization rates for their members. One of the most efficient West Coast group practices, Mullikin Medical Centers, Long Beach, Calif., now incurs only about 170 hospital days a year for each 1,000 of its members under age 65. That is barely half the national average _ but many health plans around the country say they want to emulate Mullikin’s lower hospital usage.
For anesthesiologists, lower-than-expected growth in surgery means less business. ``We can’t exactly hang out a shingle saying: `Anesthesia for Sale,‴ observes Jonathan Roth, chairman of the anesthesiology department at Albert Einstein Medical Center in Philadelphia. ``We’re dependent on the volume of surgery in hospitals.″ When managed-care plans move into a market, other anesthesiologists contend, surgery frequencies can drop 20 percent.
Charges for anesthesia services, meanwhile, are tumbling in many areas. Some managed-care plans are pressing anesthesiologists for discounts of as much as 30 percent from quoted rates. Other health plans are offering only a flat stipend of, say, 75 cents per member per month, which is meant to cover all anesthesia needs. And the federal government’s Medicare program for the elderly, which traditionally has been a big source of anesthesiologists’ income, has lately grown much stingier.
Since last year, Medicare has slashed its payments to ``care teams″ of doctors and nurses who jointly provide anesthesia in surgery. Typically, one anesthesiologist can supervise several nurse anesthetists working simultaneously in two or three different rooms. Under the old rules, anesthesiologists with enough ``care teams″ in action could earn much more than their usual solo billing rates. But Medicare’s new rules largely prevent that.
In addition, some hospitals are making much greater use of nurse anesthetists, who typically earn $80,000 a year, less than half their physician counterparts. That switch _ and its accompanying cost saving _ is becoming especially popular as more operations can be performed quickly in an outpatient setting, without the need for an overnight hospital stay.
A recent survey by Abt Associates, a Bethesda, Md., consulting firm, looked at four different ways that hospitals could mix doctors and nurses in anesthesia units. The study noted that for many procedures, nurses could be used in place of better-trained, better-paid doctors. In the most nurse-intensive scenario, Abt concluded, the U.S. already has twice as many doctors in anesthesia as it needs.
``Managed care has kicked our feet out from under us,″ says Fredrick Orkin, an anesthesiology professor at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. ``We’ve been producing new anesthesiologists at a rapid and accelerating rate. It had to reach the point where there no longer would be any jobs.″
Michael Borello, a third-year Dartmouth resident in anesthesiology, says he will avoid the job market for another year by starting a one-year advanced fellowship this summer in pain management. He hopes the additional training in a subspecialty will help his prospects. ``For residents who aren’t going the fellowship route, things are very difficult.″
The same glum tone surfaces at Boston University. ``Technology made this a very attractive specialty, but now we’ve almost saturated the market,″ says Marcelle Willock, head of BU’s anesthesiology department. One of her top trainees, Blaine Zaid, says: ``I’ve contacted 20-some hospitals, and the basic message I’m getting is that there are almost no jobs available.″
At the University of California, San Francisco, anesthesiology department chairman Ronald Miller once assumed his third-year residents could find jobs without his help. Not anymore. ``I wrote 700 letters of recommendation this year,″ Dr. Miller says. That has helped many of his 22 residents land jobs, he says, but often at much lower pay than usual.
Dr. Kwan, who did his residency and an advanced fellowship at UCSF, says he earns about $100,000 a year, shuttling from one temporary job to another. Against that income, though, he must pay for malpractice insurance, as well as various fees to join the staffs of hospitals where he works.
``This whole experience has been very educational for me,″ Dr. Kwan says. ``It’s just a question of how much longer I can take it. I’m still living in the same apartment I had at UCSF. I’m still cooking meals for myself to save money.″
Top officials at teaching hospitals are starting to shrink their anesthesiology teaching programs, so that the supply of new specialists will be more in line with reduced demand. But many hospitals aren’t cutting fast enough, says Dartmouth’s Dr. Orkin, in part because residents represent a cheap source of labor.
The biggest corrective measures may come from medical students themselves. With loans that sometimes top $100,000, medical students go to great lengths to gather information about what specialties offer the most lucrative and dependable careers. Anesthesia currently is regarded as a very bad choice.
Many teaching hospitals say that U.S. students’ applications for anesthesiology residencies are down 30 percent to 50 percent this year. Foreign medical graduates may pick up some of the slack. Even so, many training slots in anesthesia are likely to go empty next year, for lack of applicants.
Even some residents who are part-way through anesthesiology training are dropping out _ and starting over in other fields. At University of North Carolina, for example, four anesthesia residents quit this past autumn, preferring to begin a new training track in family practice or emergency medicine. ``They gave up on the field,″ says UNC’s Dr. Boysen. ``They believed that it was too much work for not enough payoff.″