the law of unintended consequences…staffing anesthesiologists

Value: easily and potentially > than $1,000,000 a year

Let’s suppose that a hospital wants fellowship trained anesthesiologists to do all their cases: pediatric anesthesia fellowship for all pediatric cases, neuroanesthesia fellowship for all neuro cases, ob-gyn fellowship for all ob-gyn cases, and cardiac fellowship for all cardia cases.  Now, for the sake of clarifying an idea, let’s suppose that this hospital has 4 surgeons: a neurosurgeon, a cardiovascular surgeon, an ob-gynecologist, and a pediatric surgeon.  Each does one case a day.  The CardioVascular surgeon does one CABG between 7:00 and 9:00 every morning.  The pediatric surgeon does a T&A between 9:30 and 10:00 every day. The neurosurgeon does a craniotomy between 11:00 and 2:00 every day; and the ob-gynecologist does a hysterectomy between 3:00 and 4:00 every day.  The routine never varies.

If the hospital is serious about requiring fellowship trained anesthesiologists for all it’s cases, then the hospital will require 4 anesthesiologists who they will subsidize because none of the anesthesiologist will be making the median income by doing only one case a day.  If the hospital does not require fellowship training, then one anesthesiologist will cover all the cases and make a good living.

Requiring fellowship training is expensive with regard to scheduling.  It may also be expensive with regard to risk to the patients.  Do you have 4 anesthesiologists on call every night?  Do the anesthesiologists need to keep up their skills by doing a variety of cases?  In the long run, is your legal risk decreased?

There can be a long debate about whether fellowship training is a good or bad thing.  Some people claim that it dumbs down anesthesiologists.  Their contention is that you never put just a head or uterus to sleep, every patient has a heart, and airway management is a practice intensive skill, so every anesthesiologist has to be aware of how to deal with sick hearts, potential strokes, and managing airways which is achieved by doing all types of cases.  Many of these skills are perfected after many years and thousand of patients.  To claim that a pediatric fellowship trained anesthesiologist (after doing between 300 and 1000  cases) is better than a non-pediatric fellowship anesthesiologist (who was trained with pediatric patients and who has done 0ver 10,000 or 20,000 pediatric cases) is sheer folly. What requiring a fellowship trained anesthesiologists does do is set a legal standard that makes it easier for lawyers to sue the hospital.  Taken to an extreme, a hospital could eventually be required to have on staff 3 or 4 times as many fellowship trained anesthesiologists as non-fellowship trained anesthesiologists to cover all the cases.

As I said, this is a thinking exercise.  Every situation is different, and I’m just trying to get across a simple idea that can become quickly complicated in terms of revenue, costs, health risk, and legal risk. For more on this, see my blog post: the fungible anesthetist… « Healthcare Systems Engineering and Analysis

A similar situation (but in reverse) has been the combining of services of multiple specialties under the domain of ‘Hospitalist’ in an effort to increase throughput and decrease costs.

About Brian D Gregory MD, MBA

Board Certified Anesthesiologist for 30 years. TOC design and implement for 30 years. MBA from U of Georgia '90: Finance, Data Management, Risk Management. Practiced in multiple US states and Saudi Arabia at KFSH&RC and KFMC Taught residents in two locations. Worked with CRNAs for 20 years.
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