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No Pain, No Gain

Planning for the brave new world of managed care, medical schools began turning out more generalists than specialists—a big miscalculation if you’re currently in need of an anesthesiologist.

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In the competition for the best medical care, New Yorkers tend to fixate on getting an appointment with one of the city’s hotshot surgeons, oncologists, or cardiologists—doctors who never seem to take new patients lacking the right connections. But unless some medical pooh-bah has a recovery plan in place, we may soon be focused on a very different challenge: the lack of an anesthesiologist to knock you out and a radiologist to interpret the MRI or CT scan that would lay out the route for the scalpel—or the laparoscopic probe. As a result of a bizarre failure to anticipate the explosion in surgical innovations (not to mention cosmetic surgery), the medical establishment hasn’t been producing enough radiologists and anesthesiologists to keep pace. There’s a nationwide shortage of radiologists—2,000, according to some estimates—and in anesthesiology, those figures run from 1,500 to 4,000. And things are deteriorating in both specialties. “By 2005, we’ll be looking at from 3,500 to 6,000,” says Kenneth Abrams, associate professor and vice-chairman of the department of anesthesiology at Mount Sinai School of Medicine.

There’s always been an ebb and flow to medical specialties. In the early nineties, primary-care physicians seemed to be at a premium, and these days some would include general surgeons and child psychiatrists on the endangered-species list. “But this has all been brought to a new level by market forces,” says Abrams.

And by miscalculations. In the early nineties, the Clintons’ push for health-care reform put pressure on residency programs to beef up their numbers in primary care, internal medicine, pediatrics, obstetrics, and gynecology. “The thinking then was that there were too many subspecialists and that the scale should be tipped,” says Bernard Birnbaum, professor of radiology at NYU Medical Center. “The government’s thinking was that it would save money because subspecialists ordered more tests and were driving up the cost of medicine.”

Around the same time, the American Society of Anesthesiologists commissioned a study to look at future employment. Word came back that there would be no growth in surgical procedures, and an unabated use of physician “extenders” like nurse anesthetists and anesthesiology assistants, resulting in an oversupply of anesthesiologists—information that, understandably, “sent an incredible ripple through the community,” says Abrams.

Consequently, med-school deans guided students away from subspecialty practices, and residency programs began reducing the number of training slots in anesthesiology and radiology. “People thought they were doing the right thing so that everybody would get a job,” says Birnbaum. “Then, as managed care started its rise, there was a general feeling among subspecialists that those who had saved enough during the course of their careers would rather get out than deal with the complexities brought to the marketplace. Many figured they’d be working harder with less compensation; the stock market was doing well, so they thought, Screw this. I’m going to retire.”

It turns out demand and supply weren’t reading from the same script. Technological innovations (CT scans, pet scans, MRIs) created an increasing need for doctors who could interpret them, for doctors skilled at reading mammograms. The machines started proliferating (more radiologists, please). Anesthesiologists, too, were expanding their field of operation: There was demand for them in cardio-catheterization labs, interventional-radiology suites, and pain-management practices.

Factor in an aging population with its attendant medical problems and the explosion of surgical innovations that are less invasive and thus less punishing to those who are in no position to take much punishment. Now add advances in monitoring technologies and in pharmaceuticals that help anesthesiologists manage a patient’s physiology. The result has been increased demand for more radiologists to read more scans and films, more anesthesiologists to put more people to sleep and wake them when it’s over.

“We’re able to more safely support patients who previously weren’t candidates for surgery because of other health issues,” says Abrams, who with his colleagues is on hand for all the new procedures but is still needed for conventional work like endovascular stent grafts via catheterization to treat aortic abdominal aneurysms, as well as the conventional surgery that features a stem-to-sternum incision and the insertion of stents via catheterization through the large vessels of the head and the neck to deal with cerebral aneurysms, as well as the conventional craniotomy—sawing through the skull.

The expansion of office-based surgery for orthopedic and cosmetic procedures, and the development and growth of free-standing ambulatory-surgery centers, have all upped the demand for anesthesiologists even more. “It lets them be owners and entrepreneurs,” says Richard Daines. It also lets them set their own hours.

All this has hobbled academic medical centers around the country—in Massachusetts, for example, the anesthesiology short count has shuttered operating rooms, delayed surgeries, reduced pain-management services—and around the state. Fifty-seven percent of the respondents to a recent New York Society of Anesthesiology survey, Abrams reports, said their institutions were looking to recruit doctors. Kings County Hospital alone has lost at least two anesthesiologists in the past four months. Mount Sinai recently tried to increase its anesthesiology-residency slots to 48 from 45 but was rebuffed by the Accreditation Council for Graduate Medical Education, which oversees the training requirements and supervision of U.S. residency programs. “I don’t know what the issue was, but it’s fair to say we were disappointed,” says Abrams.

“The city hospitals with which we’re affiliated—Elmhurst and Queens—we’ve had to support with personnel,” he adds. “We rotate some of our faculty out there to make sure those gaps are covered.”

Radiology is feeling a similar pinch. NYU is building a cancer center, and Bernard Birnbaum is working mightily to recruit physicians to staff its mammography suite. “Though mammography is a loss leader because of poor government reimbursement, we’re committed to doing it,” he says. “And if I can’t recruit enough staff, I’m going to have to pull radiologists from other locations, which means another part of our health system will be short.”

Private practice and academic centers offer their discrete enticements. The former has the bigger payday; the latter, the opportunity to do research, to teach, and to see a wide variety of cases. “We have trauma, we have open-heart,” says Daines. “Anesthesiologists at ambulatory-care centers are churning through cataracts and plastic-surgery procedures. Our selling point is We won’t bore you.”

Stiff competition has forced academic centers to start offering more than freedom from ennui. In 1998, according to the Center for Health Workforce Studies at suny Albany’s School of Public Health, the median starting salary for hospital-based graduating anesthesiology residents was $136,000. Last year, the figure was $194,000. “There’s a real burden on hospitals,” says Herbert Pardes, president and CEO of New York Presbyterian. “They have to make themselves more attractive for people to work in them.”

Nevertheless, Mount Sinai is pleased to report that of 156 graduates this year, an impressive 16 are headed for anesthesiology residencies. By contrast, of 157 graduates from NYU’s School of Medicine this year, only 4 are going into anesthesiology.

Will they stay around to practice? Manhattan and its environs present special problems for headhunters and department chairs at academic centers. “People get turned off to the cost of living in New York. They get sticker shock,” says Birnbaum. “People have heard stories that you have to be a $5 million–per–year wage earner and have influence to get into nursery schools.” Often, they seek employment elsewhere.

“People here should be concerned about the number of doctors and the quality,” says Herbert Pardes. “You need to have enough doctors, enough good doctors. If there’s a shortage, you’ll be waiting longer for services. Hopefully, the market corrects.”


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