Can Community Hospitals Be the Saviors of Anesthesiology? ~ Joseph F. Answine, MD, FASA

I was reading about a study out of University of Pittsburgh which was presented at Advance 2023 entitled “Additional anesthesiology residency positions may help hospitals save costs, address projected workforce shortages of anesthesia care professionals”.  The findings were impressive. The study showed that expanding residency positions at university hospitals can be cost-effective when compared to paying CRNAs overtime and locums rates. The savings are substantial even though the institutions have reached their cap for federal funding for residency positions. 
The Accreditation Council for Graduate Medical Education (ACGME) may grant the extra positions, but we cannot forget that residents are not interchangeable with CRNAs. CRNAs have completed their education, however, the residents are trainees. Trainees require training. They require their own education.  

Many of the university-based training programs are pushing the limit for allowable resident work hours. Furthermore, they are commonly not making didactics mandatory for residents, I assume to avoid burnout.  I have witnessed personally and heard of after-hours journal clubs, guest speaker presentations, and local conferences with few or no residents in attendance. I hope that the chair of my department during residency, Dr. Julien Biebuyck, does not hear about this trend. I imagine he may feel compelled to come out of his much-deserved retirement at 90 to re-establish order.

The programs must have educators willing to spend quality time in the operating rooms (ORs) passing on their years of anesthesia wisdom. More residents mean more educators that also happen to be in short supply.
But is it possible that expanding the already maxed-out university programs is not the only answer? Many of us with careers beginning prior to the mid-1990s can remember the community-based training programs, both allopathic and osteopathic. When the dramatic lack of interest in anesthesiology as a specialty occurred at that time, most residency spots were left unfilled. The community programs closed having to rely on other models to keep their ORs running. The university programs survived with creative maneuvers such as putting interns in the ORs by combining the clinical base and CA1 years as well as increasing the CRNA workforce. 

Due to the current overwhelming interest in anesthesiology, community-based programs are making a comeback. But many of the younger anesthesiologists are concerned with this trend. Can community hospitals train anesthesiologists as well as the universities can? 
The answer is “yes” but the education is different as I will explain below. 

I am in the ideal position to provide an answer to the question. I am “near” full-time teaching faculty within the Department of Anesthesiology and Perioperative Medicine at Penn State University Hospital. I say “near” because I also spend a week a month as core faculty at a community-based anesthesia program in Brooksville, Florida. The anesthesia program at HCA Oak Hill is in its infancy with the first 5 residents closing in on completing their CA1 years.    

The chair at Penn State is a hard-working and dedicated physician that can only afford to be clinical one day a week. This is universal among university chairs. The rest of her time is spent discussing budgets with administration, endless meetings, putting out department fires, and dealing with problem children such as the author of this story. The resident education is left to the program director (PD), assistant program director (APD), and teaching faculty. 

The chair of the department at HCA Oak Hill is equally dedicated, and also attends a few meetings, puts out an occasional department fire, and deals with problem children of course including me. He, however, has more time to be involved with resident education, and is much more clinically active.    

The PDs and APDs at Penn State and HCA Oak Hill are equally fantastic and share a love for resident and student education. But their roles are different by necessity. Penn State has over 70 residents over four years, a handful of fellows, and dozens of eager students. HCA Oak Hill will have 15 residents over three years since the clinical base year is separate from the anesthesia residency. A few transitional year residents and occasionally students are there as well. 

At Penn State, the PD’s role is more hands off with much of the education being delegated to the teaching faculty and fellows. A lot of the job involves coordinating and keeping the educational process running smoothly and up to date, She, however, does an excellent job working within such a large program. 

At Oak Hill, the PD can be very hands-on. The educational process is easier to manage, therefore, she has the ability to spend time with each resident in and out of the clinical setting.   

There is a lot more “protected time” at HCA Oak Hill for didactics, mock exams, keywords, and so on. The residents are not as essential to keep the ORs running. Resident attendance is also better during the out-of-OR educational pursuits since their presence is expected and their absence is way more obvious. Penn State has excellent Grand Rounds, resident lectures, journal clubs, and other educational pursuits. But based on sheer numbers, and the need to get through the large daily caseload, out-of-OR education including mock exams are less available and attended. 
Penn State has just about all surgical specialties represented, therefore, the availability of a diverse educational experience cannot be matched at HCA Oak Hill. Plus, many more teaching faculty at Penn State means many more years of knowledge conveyed to the residents. Experience with surgical specialties such as neurosurgery, ENT, pediatrics, and trauma cannot be obtained at HCA Oak Hill, therefore, the residents have to travel to other sites to fulfill their ACGME requirements.

As for the quality of the residents, with the trend of turning away 30%-40% of the applicants, both sites have equally bright, enthusiastic trainees. 
But the big question is the quality of education. I feel that the current five residents at HCA Oak Hill can stand up to those at any other program. But I did not tell you the whole HCA Oak Hill story. This is not their first attempt at an anesthesiology residency program. They lost their accreditation due to a revolving door of PDs, poor surgical buy-in, and dismal ACGME survey results. What I have learned by listening to the Oak Hill history and watching the current PD, APD, and teaching faculty at work is that the quality of education, especially at community-based sites, is heavily dependent on those doing the teaching. The current PD at HCA Oak Hill spent hours gaining the support of the local administration and surgeons. She also spent hours surrounding herself with an equally interested and qualified teaching faculty. 

Since the quality of education is based on the quality of the educators, there is likely to be more variability in terms of the quality of the education at community programs as they continue to mature. The university programs have established and have earned the reputation for consistent high-quality education. The community-based programs will need to do the same over time.      

In closing, with my “n” value of one, community-based programs must grow and will grow to meet the needs of the future. And, yes, they can be the saviors of anesthesiology. To do so, they require equally as high-quality educators as those currently at universities. The residents are all eager to learn. They just need us old folks to pass on all that anesthesia knowledge.